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1.  A Pilot Study of a “Resident Educator And Life-long Learner” Program: Using a Faculty Train-the-Trainer Program 
We sought to create a resident educator program using a Train-the-Trainer (TTT) approach with adaptable curricula at a large tertiary health care center with a medical school and 60 accredited residency programs.
The Resident Educator And Life-long Learner (REALL) Program was designed as a 3-phase model. Phase 1 included centralized planning and development that led to the design of 7 teaching modules and evaluation tools for TTT and resident sessions. Phase 2 entailed the dissemination of the TTT modules (Learning Styles, Observational Skills, Giving Feedback, Communication Skills: The Angry Patient, Case-Based Teaching, Clinical Reasoning, Effective Presentations) to faculty trainers. In phase 3, specific modules were chosen and customized by the faculty trainers, and implemented for their residents. Evaluations from residents and faculty were collected throughout this process.
A total of 45 faculty trainers representing 27 residency programs participated in the TTT program, and 97% of trainers were confident in their ability to implement sessions for their residents. A total of 20 trainers from 11 residency programs implemented 33 modules to train 479 residents, and 97% of residents believed they would be able to apply the skills learned. Residents' comments revealed appreciation of discussion of their roles as teachers.
Use of an internal TTT program can be a strategy for dissemination of resident educator and life-long learner curricula in a large academic tertiary care center. The TTT model may be useful to other large academic centers.
PMCID: PMC3179234  PMID: 22942958
2.  Evolutionary Game Dynamics in Finite Populations with Strong Selection and Weak Mutation 
Theoretical Population Biology  2006;70(3):352-363.
We study stochastic game dynamics in finite populations. To this end we extend the classical Moran process to incorporate frequency-dependent selection and mutation. For 2 × 2 games, we give a complete analysis of the long-run behavior when mutation rates are small. For 3 × 3 coordination games, we provide a simple rule to determine which strategy will be selected in large populations. The expected motion in our model resembles the standard replicator dynamics when the population is large, but is qualitatively different when the population is small. Our analysis shows that even in large finite populations the behavior of a replicator-like system can be different from that of the standard replicator dynamics. As an application, we consider selective language dynamics. We determine which language will be spoken in finite large populations. The results have an intuitive interpretation but would not be expected from an analysis of the replicator dynamics.
PMCID: PMC3279757  PMID: 16987535
Coordination game; Favored strategy; Frequency-dependent selection; Imitation process; Language dynamics; Moran process; Replicator dynamics; Risk-dominance; Selected strategy; Stochastic dynamics
3.  Ten steps or climbing a mountain: A study of Australian health professionals' perceptions of implementing the baby friendly health initiative to protect, promote and support breastfeeding 
The Baby Friendly Hospital (Health) Initiative (BFHI) is a global initiative aimed at protecting, promoting and supporting breastfeeding and is based on the ten steps to successful breastfeeding. Worldwide, over 20,000 health facilities have attained BFHI accreditation but only 77 Australian hospitals (approximately 23%) have received accreditation. Few studies have investigated the factors that facilitate or hinder implementation of BFHI but it is acknowledged this is a major undertaking requiring strategic planning and change management throughout an institution. This paper examines the perceptions of BFHI held by midwives and nurses working in one Area Health Service in NSW, Australia.
The study used an interpretive, qualitative approach. A total of 132 health professionals, working across four maternity units, two neonatal intensive care units and related community services, participated in 10 focus groups. Data were analysed using thematic analysis.
Three main themes were identified: 'Belief and Commitment'; 'Interpreting BFHI' and 'Climbing a Mountain'. Participants considered the BFHI implementation a high priority; an essential set of practices that would have positive benefits for babies and mothers both locally and globally as well as for health professionals. It was considered achievable but would take commitment and hard work to overcome the numerous challenges including a number of organisational constraints. There were, however, differing interpretations of what was required to attain BFHI accreditation with the potential that misinterpretation could hinder implementation. A model described by Greenhalgh and colleagues on adoption of innovation is drawn on to interpret the findings.
Despite strong support for BFHI, the principles of this global strategy are interpreted differently by health professionals and further education and accurate information is required. It may be that the current processes used to disseminate and implement BFHI need to be reviewed. The findings suggest that there is a contradiction between the broad philosophical stance and best practice approach of this global strategy and the tendency for health professionals to focus on the ten steps as a set of tasks or a checklist to be accomplished. The perceived procedural approach to implementation may be contributing to lower rates of breastfeeding continuation.
PMCID: PMC3181202  PMID: 21878131
Baby Friendly Health Initiative; breastfeeding; midwifery; health services research; dissemination of innovation; translational research
4.  The Influence of Mentorship and Role Modeling on Developing Physician–Leaders: Views of Aspiring and Established Physician–Leaders 
Journal of General Internal Medicine  2009;24(10):1130-1134.
Although the benefits of mentoring in academic medical centers have been amply discussed, the major focus has been on conferring traditional academic skills (e.g., grantsmanship, publications, etc.). In contrast, little attention has been given to the career development of physician–leaders (e.g., communication, vision, teambuilding, etc.).
To understand the role and functions of mentoring and role-modeling in developing physician–leaders as experienced by aspiring and established physician–leaders.
Qualitative design using a stratified purposeful sample and inductive analysis.
Semi-structured interviews.
Twenty-five Cleveland Clinic faculty participated (14 established physician–leaders, 11 aspiring leaders). Three themes emerged: 1. Role modeling was differentiated as a valued experience separate from mentoring, with respondents describing the significant influence of purely observational learning and “watching leaders-in-action”. 2. Many respondents favored a series of “strategic” interactions with various individuals about specific professional issues rather than traditional, longitudinal mentoring experiences. 3. Emotional and psychological support was considered the most valued type of interventional activity.
In our small sample both established and aspiring physician leaders believed that mentorship and role modeling played a significant role in their career development. Short, focused “strategic” mentoring relationships were favored by many over the classic longitudinal experience. Our participants valued role-modeling as an experience separate from mentoring and described the impact of learning from direct observation of skilled leaders. The educational implications of these findings are summarized.
PMCID: PMC2762511  PMID: 19711134
mentorship; role modeling; physician leadership
Theoretical population biology  2006;69(3):243-252.
The classical setting of evolutionary game theory, the replicator equation, assumes uniform interaction rates. The rate at which individuals meet and interact is independent of their strategies. Here we extend this framework by allowing the interaction rates to depend on the strategies. This extension leads to nonlinear fitness functions. We show that a strict Nash equilibrium remains uninvadable for non-uniform interaction rates, but the conditions for evolutionary stability need to be modified. We analyze all games between two strategies. If the two strategies coexist or exclude each other, then the evolutionary dynamics do not change qualitatively, only the location of the equilibrium point changes. If, however, one strategy dominates the other in the classical setting, then the introduction of non-uniform interaction rates can lead to a pair of interior equilibria. For the Prisoner’s Dilemma, non-uniform interaction rates allow the coexistence between cooperators and defectors. For the snowdrift game, non-uniform interaction rates change the equilibrium frequency of cooperators.
PMCID: PMC2880897  PMID: 16427669
Journal of theoretical biology  2006;243(2):245-251.
In this paper, we show that for evolutionary dynamics between two types that can be described by a Moran process, the conditional fixation time of either type is the same irrespective of the selective scenario. With frequency dependent selection between two strategies A and B of an evolutionary game, regardless of whether A dominates B, A and B are best replies to themselves, or A and B are best replies to each other, the conditional fixation times of a single A and a single B mutant are identical. This does not hold for Wright-Fisher models, nor when the mutants start from multiple copies.
PMCID: PMC2879639  PMID: 16890959
7.  Exploring Leadership Competencies in Established and Aspiring Physician Leaders: An Interview-based Study 
Background and Objectives
Academic health care institutions have become interested in understanding and supporting current leaders and preparing leaders for the future. We designed this exploratory study to better understand specific perceived leadership needs of physicians from the perspective of “aspiring” and “established” leaders within our institution.
A qualitative, inductive, structured interview-based design was used to examine the study questions.
A purposeful sample of current and aspiring leaders was obtained, sampling across specialties and levels of leadership.
All participants were interviewed by the same investigator (CT). Five open-ended questions were developed as prompts. Two of the investigators independently analyzed the transcripts, using an open coding method to identify themes within the narratives. Inter-observer comparisons were made and discrepancies were resolved through discussion.
Four themes emerged from analyzing the responses to our questions. Aspiring and established leaders agreed that “knowledge”, “people skills” or emotional intelligence, and “vision” were all characteristics of effective leaders and critical to the success of aspiring leaders. Established leaders in our sample added a characteristic of “organizational orientation” that extended the description of “leaders” to include an understanding of the institution as well as dedication to its success (a trait we have called “organizational altruism”).
Our findings validate others’ regarding leadership competencies while extending these findings to the specific context of health care and physicians. Important implications for curricular design include: inclusion of emotional intelligence competencies and reducing formal didactics in favor of programs that are both interactive and problem-based.
PMCID: PMC2517871  PMID: 18327531
leadership competency; great leaders; organizational success; leadership development
Evolutionary ecology research  2007;9(6):1023-1041.
Whether or not cooperation can be enhanced if players with a performance higher than the mean are forced to pay an additional cost in each generation?
Mathematical Methods
Analysis of replicator dynamics with mutation. The ESS distribution of cooperation level is obtained.
Key Assumptions
Players engage in cooperative dilemma game, and at the end of each generation, those with higher performance than the mean are forced to pay additional cost.
Without mutation, the entire population eventually conforms to a single cooperation level determined by the initial composition of the population. With mutation, there is an equilibrium distribution of cooperation level, which has a peak at an intermediate level of cooperation. Whether it is institutionalized such as tax or just a social custom, fitness adjustment based ultimately on people’s emtion of “envy” is able to maintain cooperation.
PMCID: PMC2600810  PMID: 19079742
9.  Transforming the dilemma 
How does natural selection lead to cooperation between competing individuals? The Prisoner's Dilemma captures the essence of this problem. Two players can either cooperate or defect. The payoff for mutual cooperation, R, is greater than the payoff for mutual defection, P. But a defector versus a cooperator receives the highest payoff, T, while the cooperator obtains the lowest payoff, S. Hence, the Prisoner's Dilemma is defined by the payoff ranking T > R > P > S. In a well-mixed population, defectors always have a higher expected payoff than cooperators, and therefore natural selection favors defectors. The evolution of cooperation requires specific mechanisms. Here we discuss five mechanisms for the evolution of cooperation: direct reciprocity, indirect reciprocity, kin selection, group selection and network reciprocity (or graph selection). Each mechanism leads to a transformation of the Prisoner's Dilemma payoff matrix. From the transformed matrices, we derive the fundamental conditions for the evolution of cooperation. The transformed matrices can be used in standard frameworks of evolutionary dynamics such as the replicator equation or stochastic processes of game dynamics in finite populations.
PMCID: PMC2396516  PMID: 17711471
Prisoner's Dilemma; evolution of cooperation; direct and indirect reciprocity; kin selection; group selection; network (graph) selection

Results 1-9 (9)