David Berg

Yale University, New Haven, Connecticut, United States

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Publications (27)137.77 Total impact

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    ABSTRACT: High rates of attrition from general surgery residency may threaten the surgical workforce. We sought to gain further insight regarding resident motivations for leaving general surgery residency. We conducted in-depth interviews to generate rich narrative data that explored individual experiences. An interdisciplinary team used the constant comparative method to analyze the data. Four themes characterized experiences of our 19 interviewees who left their residency program. Participants (1) felt an informal contract was breached when clinical duties were prioritized over education, (2) characterized a culture in which there was no safe space to share personal and programmatic concerns, (3) expressed a scarcity of role models who demonstrated better work-life balance, and (4) reported negative interactions with authority resulting in a profound loss of commitment. As general surgery graduate education continues to evolve, our findings may inform interventions and policies regarding programmatic changes to boost retention in surgical residency. Copyright © 2015 Elsevier Inc. All rights reserved.
    No preview · Article · Jul 2015 · American journal of surgery
  • Marjorie Rosenthal · David Berg

    No preview · Article · Apr 2015 · The Clinical Teacher
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    Full-text · Article · May 2014 · PLoS Pathogens
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    ABSTRACT: Background: The value of community-engaged research (CER ) to understand health inequities and create sustainable interventions is well known. However, research on the dynamics of community-academic partnerships has been conducted and interpreted almost exclusively by academic researchers. We sought authentic perspectives of community-based organizations (CBO) on CER partnerships. Methods: A CBO leader and a university researcher partnered, using in-depth interviews, to systematically assess the experiences and perspectives of CBO leaders and university researchers engaged in research relationships. In an attempt to elicit candid responses, the CBO co-researcher interviewed 10 CBO leaders, and the university co-researcher interviewed 10 university researchers. We used the constant comparative method of qualitative analysis. Results: Many participants described CER as valuable for building capacity for CBOS and academics, and as beneficial to the community. However, CBO leaders and academics differed on the importance of race, power and privilege in CER: CBO leaders described how an open conversation on these issues is crucial for a mutually respectful collaboration and academic researchers described these issues as residing in the past. Conclusion: Despite the years since the well-known research abuses involving communities of color, issues of race, power and privilege remain polarizing forces in academic-community research partnerships. As these issues influence the level of trust and commitment community partners bring to research collaborations, they need to be addressed before an equitable collaboration can occur.
    No preview · Conference Paper · Nov 2013
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    ABSTRACT: Background: Creating and sustaining collaborations between community-based organizations (CBO) and university researchers in community-engaged research (CER) requires commitments from both groups. Few studies have explored how, and to what extent, such research partnerships help both partners achieve their career goals and organizational missions. To gain a greater understanding of these experiences, we assessed the perspectives of community leaders and university researchers conducting CER in a medium-sized city with a history of community-university tension. Methods: We performed qualitative key informant interviews and purposeful, snowball sampling. A CBO researcher interviewed 10 CBO leaders, and a university researcher interviewed 10 community-engaged university researchers. We audio-taped and professionally transcribed interviews. Our team of experts in organizational theory and community-based participatory research performed analyses using the constant comparative method. Interviews continued until we reached thematic saturation. Results: Themes revealed multilevel challenges for supporting community-engaged university researchers in sustainable community-university relationships, specifically the relationships between the 1) university researcher and community leader, including the interpersonal relationship and the influence of the past on their current research relationship; 2) university researcher and his or her institution, including the professional and financial investment of the university in the researcher; and 3) university and CBOs, including differences in mission, including any tensions historically in the relationship between the institutions, and the view of community-engaged university researchers as different from other university researchers. Conclusion: Many challenges exist in developing and sustaining university researchers in community-university partnerships. Interventions are needed at multiple levels, within and between institutions, to improve these partnerships.
    No preview · Conference Paper · Nov 2013
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    ABSTRACT: Efficient spreading of evidence-based innovations among complex health systems remains an elusive goal despite extensive study in the social sciences. Biology provides a model of successful spread in viruses, which have evolved to spread with maximum efficiency using minimal resources. Here we explore the molecular mechanisms of human immunodeficiency virus (HIV) spread and identify five steps that are also common to a recent example of spread in complex health systems: reduction in door-to-balloon times for patients with ST-segment elevation myocardial infarction (STEMI). We then describe a new model we have developed, called AIDED, which is based on mixed-methods research but informed by the conceptual framework of HIV spread among cells. The AIDED model contains five components: Assess, Innovate, Develop, Engage and Devolve, and can describe any one of the following: the spread of HIV among cells, the spread of practices to reduce door-to-balloon time for patients with STEMI and the spread of certain family health innovations in low- and middle-income countries. We suggest that by looking to the biological sciences for a model of spread that has been honed by evolution, we may have identified fundamental steps that are necessary and sufficient for efficient, low-cost spread of health innovations among complex health systems.
    Preview · Article · May 2013 · International Journal for Quality in Health Care
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    Preview · Dataset · Aug 2012
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    Preview · Dataset · Aug 2012
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    ABSTRACT: Many family health innovations that have been shown to be both efficacious and cost-effective fail to scale up for widespread use particularly in low-income and middle-income countries (LMIC). Although individual cases of successful scale-up, in which widespread take up occurs, have been described, we lack an integrated and practical model of scale-up that may be applicable to a wide range of public health innovations in LMIC. To develop an integrated and practical model of scale-up that synthesises experiences of family health programmes in LMICs. We conducted a mixed methods study that included in-depth interviews with 33 key informants and a systematic review of peer-reviewed and grey literature from 11 electronic databases and 20 global health agency web sites. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS: We included key informants and studies that reported on the scale up of several family health innovations including Depo-Provera as an example of a product innovation, exclusive breastfeeding as an example of a health behaviour innovation, community health workers (CHWs) as an example of an organisational innovation and social marketing as an example of a business model innovation. Key informants were drawn from non-governmental, government and international organisations using snowball sampling. An article was excluded if the article: did not meet the study's definition of the innovation; did not address dissemination, diffusion, scale up or sustainability of the innovation; did not address low-income or middle-income countries; was superficial in its discussion and/or did not provide empirical evidence about scale-up of the innovation; was not available online in full text; or was not available in English, French, Spanish or Portuguese, resulting in a final sample of 41 peer-reviewed articles and 30 grey literature sources. We used the constant comparative method of qualitative data analysis to extract recurrent themes from the interviews, and we integrated these themes with findings from the literature review to generate the proposed model of scale-up. For the systematic review, screening was conducted independently by two team members to ensure consistent application of the predetermined exclusion criteria. Data extraction from the final sample of peer-reviewed and grey literature was conducted independently by two team members using a pre-established data extraction form to list the enabling factors and barriers to dissemination, diffusion, scale up and sustainability. The resulting model-the AIDED model-includes five non-linear, interrelated components: (1) assess the landscape, (2) innovate to fit user receptivity, (3) develop support, (4) engage user groups and (5) devolve efforts for spreading innovation. Our findings suggest that successful scale-up occurs within a complex adaptive system, characterised by interdependent parts, multiple feedback loops and several potential paths to achieve intended outcomes. Failure to scale up may be attributable to insufficient assessment of user groups in context, lack of fit of the innovation with user receptivity, inability to address resistance from stakeholders and inadequate engagement with user groups. The inductive approach used to construct the AIDED model did not allow for simultaneous empirical testing of the model. Furthermore, the literature may have publication bias in which negative studies are under-represented, although we did find examples of unsuccessful scale-up. Last, the AIDED model did not address long-term, sustained use of innovations that are successfully scaled up, which would require longer-term follow-up than is common in the literature. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS: Flexible strategies of assessment, innovation, development, engagement and devolution are required to enable effective change in the use of family health innovations in LMIC.
    Full-text · Article · Jul 2012 · BMJ Open
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    ABSTRACT: Although the number of women entering medical school has been steadily rising in the U.S.A., female medical students continue to report instances of sexual harassment and gender discrimination. The full spectrum of such experiences and their effect on the professional identity formation of female students over time remains largely unknown. To investigate these experiences, we interviewed 12 third year female medical students at a private New England medical school over several points during the 2006-2007 academic year. Using theoretical frameworks of gender performance and the centrality of student-patient and student-supervisor relationships, we were better able to understand how female medical students interpret the role of 'woman doctor' and the effect of negative and positive gendered interactions on the evolution of their professional identity. We found that participants quickly learned how to confront and respond to inappropriate behavior from male patients and found interactions with female patients and supervisors particularly rewarding. However, they did not feel equipped to respond to the unprofessional behavior of male supervisors, resulting in feelings of guilt and resignation over time that such events would be a part of their professional identity. The rapid acculturation to unprofessional behavior and resignation described by participants has implications for not only professional identity formation of female students but specialty choices and issues of future physician workforce.
    No preview · Article · Apr 2012 · Social Science [?] Medicine
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    ABSTRACT: This article explores the group dynamics of mixed methods health sciences research teams. The authors conceptualize mixed methods research teams as “representational groups,” in which members bring both their organizational and professional groups (e.g., organizational affiliations, methodological expertise) and their identity groups, such as gender or race, to the work of research. Although diversity and complementarity are intrinsic to mixed methods teams, these qualities also present particular challenges. Such challenges include (a) dealing with differences, (b) trusting the “other,” (c) creating a meaningful group, (d) handling essential conflicts and tensions, and (e) enacting effective leadership roles. The authors describe these challenges and, drawing from intergroup relations theory, propose guiding principles that may be useful to mixed methods health sciences research teams.
    Full-text · Article · Jan 2012 · Journal of Mixed Methods Research
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    ABSTRACT: Although interdisciplinary hospital quality improvement (QI) teams are both prevalent and associated with success of (QI) efforts, little is known about the behaviors of successful interdisciplinary QI teams. We examined the specific behaviors of interdisciplinary QI teams in hospitals that successfully redesigned care for patients with ST-elevation myocardial infarction (STEMI) and reduced door-to-balloon times. Qualitative study. Researchers interviewed 122 administrators, providers, and staff in 11 hospitals with substantial improvements in door-to-balloon times. Using data from the in-depth qualitative interviews, the authors identified themes that described the behaviors of interdisciplinary QI teams in successful hospitals. Teams focused on 5 behaviors: (1) motivating involved hospital staff toward a shared goal, (2) creating opportunities for learning and problem-solving, (3) addressing the impact of changes to care processes on staff, (4) protecting the integrity of the new care processes, and (5) representing each involved clinical discipline effectively. The behaviors observed may enhance a QI team's ability to motivate the various disciplines involved, understand the care process they must change, be responsive to front-line concerns while maintaining control over the improvement process, and share information across all levels of the hospital hierarchy. Teams in successful hospitals did not avoid interdisciplinary conflict, but rather allowed each discipline to contribute to the team from its own perspective. Successful QI teams addressed the concerns of each involved discipline, modified protocols guided by clinical outcomes, and became conduits of information on changes to care processes to both executive managers and front-line staff.
    No preview · Article · Nov 2011 · Journal of Hospital Medicine
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    ABSTRACT: Despite a long history of international medical graduates (IMGs) coming to the United States for residencies, little research has been done to find systematic ways in which residency programs can support IMGs during this vulnerable transition. The authors interviewed a diverse group of IMGs to identify challenges that might be eased by targeted interventions provided within the structure of residency training. In a qualitative study conducted between March 2008 and April 2009, the authors contacted 27 non-U.S.-born IMGs with the goal of conducting qualitative interviews with a purposeful sample. The authors conducted in-person, in-depth interviews using a standardized interview guide with potential probes. All participants were primary care practitioners in New York, New Jersey, or Connecticut. A total of 25 IMGs (93%) participated. Interviews and subsequent analysis produced four themes that highlight challenges faced by IMGs: (1) Respondents must simultaneously navigate dual learning curves as immigrants and as residents, (2) IMGs face insensitivity and isolation in the workplace, (3) IMGs' migration has personal and global costs, and (4) IMGs face specific needs as they prepare to complete their residency training. The authors used these themes to inform recommendations to residency directors who train IMGs. Residency is a period in which key elements of professional identity and behavior are established. IMGs are a significant and growing segment of the physician workforce. Understanding particular challenges faced by this group can inform efforts to strengthen support for them during postgraduate training.
    Full-text · Article · Sep 2011 · Academic medicine: journal of the Association of American Medical Colleges
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    Preview · Dataset · Sep 2011
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    Preview · Dataset · Sep 2011
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    ABSTRACT: Objectives Physician migration from low-income to high-income nations is a global concern. Despite the centrality of understanding the perspectives of international medical graduates (IMGs) who have experienced migration to understanding the causes and consequences of this phenomenon, empirical literature is limited. The authors sought to characterise the experiences of IMGs from limited resource nations currently practicing primary care in the USA, with a focus on their perspectives on physician migration. Design The authors conducted a qualitative study utilising in-depth, in-person interviews and a standardised interview guide. The sample comprised a diverse, purposeful sample of IMGs (n=25) from limited resource nations (defined as having ≤2 physicians per 1000 population). Results Analyses revealed four recurrent and unifying themes reflecting the perspectives of IMGs in the USA on physician migration: (1) decisions to migrate were pragmatic decisions made in the context of individual circumstance; (2) the act of migration ultimately affected participants' ability to return home in multiple, unpredictable ways; (3) the ongoing process of acclimation was coupled with inherent conflicts surrounding the decision to remain in the USA; and (4) the effects of policies in both the home country and in the USA occurred at multiple levels. Conclusion The perspectives of IMGs who have migrated to the USA are an important addition to the ongoing discussion surrounding the global health workforce. Our findings highlight the effects of workforce policies which are often developed and discussed in abstraction, but have real, measurable impacts on the lives of individuals. Future efforts to address physician migration will need to acknowledge the immediate needs of the health workforce as well as the long-term needs of individuals within health systems.
    Full-text · Article · Sep 2011 · BMJ Open
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    Preview · Dataset · Sep 2011
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    ABSTRACT: Mortality rates for patients with acute myocardial infarction (AMI) vary substantially across hospitals, even when adjusted for patient severity; however, little is known about hospital factors that may influence this variation. To identify factors that may be related to better performance in AMI care, as measured by risk-standardized mortality rates. Qualitative study that used site visits and in-depth interviews. Eleven U.S. hospitals that ranked in either the top or the bottom 5% in risk-standardized mortality rates for 2 recent years of data from the Centers for Medicare & Medicaid Services (2005 to 2006 and 2006 to 2007), with diversity among hospitals in key characteristics. 158 members of hospital staff, all of whom were involved with AMI care at the 11 hospitals. Site visits and in-depth interviews conducted with hospital staff during 2009. A multidisciplinary team performed analyses by using the constant comparative method. Hospitals in the high-performing and low-performing groups differed substantially in the domains of organizational values and goals, senior management involvement, broad staff presence and expertise in AMI care, communication and coordination among groups, and problem solving and learning. Participants described diverse protocols or processes for AMI care (such as rapid response teams, clinical guidelines, use of hospitalists, and medication reconciliation); however, these did not systematically differentiate high-performing from low-performing hospitals. The qualitative design informed the generation of hypotheses, and statistical associations could not be assessed. High-performing hospitals were characterized by an organizational culture that supported efforts to improve AMI care across the hospital. Evidence-based protocols and processes, although important, may not be sufficient for achieving high hospital performance in care for patients with AMI. Agency for Healthcare Research and Quality, United Health Foundation, and the Commonwealth Fund.
    Full-text · Article · Mar 2011 · Annals of internal medicine
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    ABSTRACT: International medical graduates (IMGs) comprise approximately 25% of the US physician workforce, with significant representation in primary care and care of vulnerable populations. Despite the central role of IMGs in the US healthcare system, understanding of their professional experiences is limited. To characterize the professional experiences of non-US born IMGs from limited-resource nations practicing primary care in the US. Qualitative study based on in-depth in-person interviews. Purposeful sample of IMGs (n = 25) diverse in country of origin, length of practice in the US, specialty (internal medicine, family medicine and pediatrics), age and gender. Participants were currently practicing primary care physicians in New York, New Jersey or Connecticut. A standardized interview guide was used to explore professional experiences of IMGs. Four recurrent and unifying themes characterize these experiences: 1) IMGs experience both overt and subtle forms of workplace bias and discrimination; 2) IMGs recognize professional limitations as part of "the deal"; 3) IMGs describe challenges in the transition to the culture and practice of medicine in the US; 4) IMGs bring unique skills and advantages to the workplace. Our data reveal that IMGs face workplace challenges throughout their careers. Despite diversity in professional background and demographic characteristics, IMGs in our study reported common experiences in the transition to and practice of medicine in the US. Findings suggest that both workforce and workplace interventions are needed to enable IMG physicians to sustain their essential and growing role in the US healthcare system. Finally, commonalities with experiences of other minority groups within the US healthcare system suggest that optimizing IMGs' experiences may also improve the experiences of an increasingly diverse healthcare workforce.
    Full-text · Article · Sep 2010 · Journal of General Internal Medicine
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    ABSTRACT: To examine the role of microsystem characteristics in the translation of an evidence-based intervention (the Diabetes Prevention Initiative (DPI)) into practice in a community-health centre (CHC). Case study. Constant comparative method of qualitative analysis. Community-health centre in a mid-sized city in the USA. 27 administrators, clinicians and staff of a community-health centre implementing a DPI. Perceptions of microsystem characteristics that influence the implementation of this initiative. Five characteristics of high-performing microsystems were reflected, but not maximised, in the implementation of the DPI. First, there was no universally shared definition of the desired purpose of the DPI. Second, investment in quality improvement (QI) was strong, yet sustainability remained a concern, since efforts were dependent upon external grant support. Third, lack of cohesiveness between the initiative planning team and the rest of the organisation served to both facilitate and constrain implementation. Fourth, administrators showed both support for new initiatives and a lack of strategic vision for QI. Fifth, this initiative substantially strained already-stretched role definitions. Translation of the DPI in this CHC was constrained by the lack of a cohesive QI infrastructure and incomplete alignment with characteristics of high-performing microsystems. The findings suggest an important role for microsystem characteristics in the process of implementing evidence-based interventions. Enhancing the level of microsystem performance of CHCs is essential to informing efforts to improve quality of care in this critical safety-net system.
    No preview · Article · Aug 2010 · Quality and Safety in Health Care