To the Editor: As medical trainees, the enthusiasm with which we begin our chosen professions is often tempered by difficult realities of the U.S. health care system. The massive scale of problems, such as the expanding costs of care, insufficient insurance coverage, or widespread racial inequalities, are enough to paralyze even the most resilient students. Furthermore, many of us feel a growing sense of detachment and distance from the issues that inspired us to enter medicine in the first place. In the context of busy clinical schedules, rigorous educational standards, and much needed self-care, what could a trainee possibly contribute to issues facing the U.S. health care system? One possible answer lies within the world of health services research. Using the tools of economics, statistics, and epidemiology, trainees have the potential to generate high-quality evidence and support tangible changes to health care policy and legislation. 1 In 2020, 2 general surgery residents at the University of Michigan investigated rates of surprise, out-of-network billing using a database of private insurance claims. Of nearly 350,000 elective surgeries examined, they found 20% of patients received a surprise bill. 2 Their research not only generated a wave of press but was also directly cited in congressional testimony. The federal No Surprises Act was passed with bipartisan support in early 2021 and took effect in 2022, creating new consumer protections for patients and families across the country. 3 Similarly, in 2020, a group of students at Harvard Medical School used the National Health and Nutrition Examination Survey to evaluate potential racial disparities in the diagnosis of chronic kidney disease. 4 By removing race as a variable from equations estimating kidney function, they found a significantly higher proportion of Black adults who meet criteria for end-stage kidney disease. The following year, their work was cited in new guidelines developed by a joint task force from the National Kidney Foundation and American Society of Nephrology, recommending the exclusion of race from calculations of kidney function. 5 By consistently reading the medical literature and acquiring basic statistical programming skills, clinical trainees may uncover opportunities to apply health service research methods to meaningful policy questions within their domains of interest, and emulate the success of the above precedents.

To the Editor: In ten Cate’s Invited Commentary on the ethics of health professions education (HPE) research (HPE-R), 1 he provides 27 lessons in HPE ethics and states the importance of discussions to develop ethical integrity. We believe some issues he addresses could benefit from further discussion and clarification, including (1) context and organization of HPE-R ethical review (ER), and (2) meaning of ER decisions. Although ten Cate states that “international variations in habits, rules, and regulations do not strike the author as being substantially different,” there are significant differences in context and organization of HPE-R. 2 These differences can result in differing ER processes (i.e., review time, required changes) and decisions (i.e., exempt or approval after full or expedited review) of the exact same protocol, even within one country. 3 Moreover, the meaning of the ER decision “exempt” varies considerably between countries. 4 Given the differences in context and organization, terminology matters. Twice ten Cate refers to ER requirements. First, writing, “Most grant funders and HPE journals require ethical review of empirical studies,” and second, writing, “obtaining ethical approval has become standard for most research in HPE.” 1 There are differences between “requiring ethical review” and “obtaining ethical approval,” and these differences are not only linguistic, but they have significant implications. Requiring review does not necessarily mean approval is granted, implying “exempt” decisions may be accepted. Actually, “exempt” decisions could encompass no review at all, not falling under the scope of applicable rules/regulations in some countries. Reporting only the ER decision “exempt,” without considerations, is a shortcut that creates ambiguity and hampers critical reflection on research practice both by the researchers and for the HPE community to assess the quality of the work. This was illustrated by Hally and Walsh who reviewed publications in 4 main HPE journals and revealed dubious statements indicating unrequired/exempted ER, often without further explanation. 5 A key lesson is that ethical considerations and procedures, such as recruitment, informed consent, prevention of pressure to participate, data handling/management, and protection should be described for the HPE community to be able to assess whether the research meets our common ethical standards. HPE-R is reviewed in context—in different countries and committees with different rules/regulations. To ensure ethical integrity, it is essential to make considerations of researchers explicit to overcome differences in terminology.

We thank Cummings and Kumar for their comments on our article and for recognizing the importance of an intersectional framework. Regarding individual barriers, many of the 10 items reflected on our survey captured participants’ (in)ability to meet their health care needs, including due to finances, such as “not filling a prescription for medicine because of the out-of-pocket cost.” The root causes of these access disparities are socioeconomic and driven by racism, biphobia, and homophobia. Although socioeconomic differences accounted for the majority of the racial/ethnic access disparities we observed, socioeconomic disadvantage was prevalent among sexual and intersectional minorities. Structural-level housing, employment, income, and educational discrimination are rampant. Gentrification and redlining, the discriminatory practice of limiting housing access based on race, continue to displace Black and Brown people from equitable housing and education. Sexual minorities are routinely forced into homelessness by unsupportive families, and it is still legal to fire someone for being lesbian, gay, bisexual, transgender, and queer (LGBTQ+) in a large portion of the United States. These structural factors require targeted intervention to improve access to care for these populations. We also greatly appreciate Cummings and Kumar’s discussion of the importance of the visibility, recruitment, and retention of racial/ethnic and sexual minorities within academic medicine. Despite an increased recognition of the importance of diversity for cultural competency efforts, diversity has not been as prioritized at the faculty and leadership levels. Racial/ethnic and sexual minority diversity at every level is necessary for culturally competent care. To this point, survey items, such as “How satisfied are you with the health care you received during your most recent medical care visit?” captured cultural competency in interactions with providers. Equitable hiring criteria are critical, like not limiting high-level positions to graduates of predominantly White institutions and both identifying and addressing aversive racism during the hiring process. It is also important to evaluate practices and develop structural supports to help retain and advance underrepresented practitioners and educators. This involves redefining institutional measures of success to include efforts that increase diversity, promote equity, engage the community, and support retention and advancement of racial/ethnic and sexual minority practitioners. To achieve such a cultural shift, it is exceptionally important to hire and empower equity officers to change institutional policy. We cannot agree more that diversifying the workforce at all levels, particularly within an intersectional framework, is necessary for creating a medical community prepared to care for an increasingly diverse nation. This, coupled with broader health system policies to address structural issues that disadvantage LGBTQ+ people of color, is a necessary strategy to achieve health equity.

As a promising noise control material, micro-perforated panel absorbers satisfy the trend towards a greener environment and energy efficiency. Any thin, planar material, when perforated with sub-millimeter pores of a certain depth and combined with a finite-depth air space, can be a good noise absorber. Compared with traditional porous (i.e., fibrous) materials, a micro-perforated structure is more friendly to the environment and more resistant to severe working conditions. The fundamental absorption mechanism of these systems is investigated here, including a discussion of pore end corrections. The Maa model has been successfully applied to the design of practical micro-perforated (MPP's) absorbers. However, recent studies have shown that a rigid perforated plate can be modeled as an equivalent fluid following the Johnson-Allard approach when an equivalent tortuosity is defined appropriately. In this thesis, a new finite element model of micro-perforated panels is proposed. By using existing finite element models of rigid porous materials, it has been shown that the acoustic properties of rigid micro-perforated panels can be successfully predicted. Furthermore, that approach can be extended to flexible micro-perforated panels, which can be modeled similarly by using poro-elastic finite elements. The finite element predictions were found to agree well with both measurements and analytical, planar models that allow for panel flexibility. Moreover, the finite element models are particularly useful when dealing with complex configurations and geometries, such as curved panels and segmented backing spaces. Accurate acoustical measurements of micro-perforated panels were implemented in the process of model validations. With the advance of standing wave tube measurements, the latest four-microphone measurements can provide more accurate estimates of material properties than could be obtained using the two-microphone method. Some concerns related to standing wave tube measurements are discussed, including correction for microphone mismatch, tube attenuation and the effect of circumferential boundary conditions. Several calibration methods for the standing wave tube are proposed to make this technique more reliable and accurate.

1S. Rosenzweig is professor, Department of of Emergency Medicine (Hospice and Palliative Medicine), and director, Office of Community Engagement, Drexel University College of Medicine, Philadelphia, Pennsylvania; telephone: email: [email protected]. Acknowledgements: I have ongoing gratitude for my collaborator at the Philadelphia Museum of Art, Danielle Rice, PhD (1951-2019), whose energy and guidance shaped this program.

Tielemans, Claudia J.M. MSc1; Eijkelboom, Charlotte M.C.L. MSc2; Lesterhuis, Marije PhD3; de Vreugd, Lars B. MSc4; Pennings, Helena J.M. PhD5; de Kleijn, Renske A.M. PhD6 Author Information

Incorporating patient and family voices in the development of entrustable professional activities (EPAs) is not standard practice. Care of children with medical complexity (CMC) is an area of pediatrics that relies on family partnership, and families of CMC are ideal partners in EPA development given their expertise in their child's care and experience interacting with the health care system. The authors describe their model for partnering with families to develop EPAs and reflect on the unique contributions of family leaders to the process. After recruitment of family leaders from a national organization of families and friends of children with special health care needs, the authors used a multistage process for EPA development from June 2019 to February 2021. Family leaders were integrated throughout the process, including creating EPA descriptions, revising content across all EPAs, appraising EPAs through virtual focus groups with other key stakeholders, and finalizing and publishing EPAs. The authors used content analysis to identify recommendations for patient- and family-integrated EPA development. Family leaders and educators partnered in every phase of developing EPAs for the care of CMC, including as content experts, editors, focus group facilitators, and coauthors. Family leaders recommended substantive changes to all EPAs, including revising language, augmenting content, and modifying scope of practice. In addition, content analysis of family leaders' revisions yielded 10 recommendations to ensure that written EPA descriptions are patient- and family-centered. The described process of EPA development for the care of CMC models how families can be integrated into competency framework development and highlights their contributions. Family leader recommendations for embedding patient and family voices in EPA descriptions can serve as a guide for EPA development in other specialties.

“Inna lillahi wa inna ilayhi raji’un,” I whispered under my breath. It was the universal prayer Muslims say when a fellow Muslim passes away, roughly translating to, “To God we belong, and to God we return.” I had said this prayer many times before for loved ones and community members, but that was the first time I had uttered those words for a patient. I sat in the empty Spirituality Center of the hospital where I observed my daily prayers during long internal medicine call shifts. Just 24 hours earlier, I had been in the room of my elderly Muslim patient, Mr. M, with the rest of the team for daily rounds. In between answering routine medical questions, Mr. M slipped into reciting Arabic prayers and verses from the Qur’an. My ears perked up in those moments—words in the conversation I actually understood, unlike his native tongue or even the medical jargon my attending and residents used. While the rest of the team put in orders and adjusted his breathing mask, I stood next to Mr. M, listening to his Arabic prayers voicing understanding that it was his time and asking for a painless death. Recognizing me as a Muslim by my headscarf, Mr. M asked if I spoke his native tongue. I shook my head no and apologized, then added, “I can pray for you though,” excited by any opportunity to help in his care. He nodded. I began to quietly recite all the Arabic prayers I knew for him. Mr. M passed away after I left the hospital that day. I grappled with his loss days after his passing. I was not sure if it was my naiveté as a medical student witnessing her first patient death or the moments I shared with Mr. M praying in our common tongue and shared faith that made me feel big emotions I was not sure how to process. While his death was expected given his condition, I was still stunned by its occurrence, its finality, and its permanence. One week later, I experienced the death of another patient, Mr. B, which solidified why Mr. M’s loss had been so devastating. On the outside, Mr. B and I were nothing alike: me, a petite Brown woman, and him, a White man so tall he barely fit in the hospital bed. We had no common tongue or faith, nor had we prayed side-by-side in our last moments together, as I had with Mr. M. Instead, the last conversation I had with Mr. B was about our love for the same hospital cafeteria sandwich: a tuna melt. We extensively discussed the best tuna melts we had eaten before and scorned those who did not appreciate its delicacy. Our conversations evolved from sandwiches to cooking to travel as we searched for other similarities. I had learned grief was the profound sorrow someone feels after the loss of someone to whom they had a bond or affection for. I did not expect to feel this way about patients who I had only known in sickness, not in health. Mr. M and Mr. B reminded me that finding threads of commonality—a faith, a language, a favorite sandwich—can form bonds that defy the lack of time together. While having these connections made their deaths harder to process, it made me appreciate their lives more. I keep the stories of Mr. M and Mr. B close to my heart and allow them to inspire how I approach my interactions with other patients. I remember prayers and tuna melts as I sit next to new patients, determined to find something, big or small, to connect us. When we form enriched relationships, we allow ourselves to feel grief for the patients we lose, and likewise, joy for the patients who leave healthier than when they arrived.

[Summary: The Shape of Water, the 2017 award-winning film by Mexican director Guillermo del Toro, is an adult fairy tale that conducts the audience through the romance of two misunderstood voiceless creatures who, after a long time, find their complement in each other. Elisa Esposito is a mute woman whose last name alludes to her orphanhood and loneliness residing in a world of archetypal normality where the one who is seen as different becomes either invisible or threatening. Immersed in a cold and rigid world of science, she is a passive observer colored by several shades of green and blue reflected on her clothing, a symbol of her adaptability to that intransigent context. Her normality consists of watching movies, boiling the eggs she eats at lunch, preparing her tub to accomplish her daily masturbatory ritual, contemplating an inspirational phrase on her calendar, neatly cleaning her black shoes, longing for a pair of red shoes, and taking care of her neighbor Giles, a socially rejected gay man culturally forced to repress his emotions who sees himself as a relic for being old and misunderstood by his peers. Elisa’s life is changed when a humanoid amphibian creature arrives in the government laboratory where she works as a janitor. The creature is to be the focus of painful experiments; Elisa identifies with and begins to love him. The Shape of Water narrates the story of a group of socially and culturally neglected people whose physical and individual differences seem to marginalize them from the world but actually connect them through the one thing they have in common: their belonging to otherness. In the following excerpt, Elisa signs the dialogue, which Giles then interprets aloud.] ELISA: What am I? I move my mouth, like him. I make no sound, like him. What does that make me? All that I am, all that I’ve ever been, brought me here to him…. When he looks at me, the way he looks at me, he doesn’t know what I lack or how I am incomplete. He sees me for what I am as I am. He’s happy to see me every time, every day.