Abstract
OBJECTIVE
To objectively measure the current demographic makeup of the American College of Veterinary Surgeons (ACVS) diplomates and to develop a survey tool to be used as a metric to measure future changes in the ACVS demographic profile.
SAMPLE
737 ACVS diplomates.
METHODS
A 14-item electronic survey was sent to 2,199 ACVS diplomates between August 25 and September 9, 2021, via email. Survey items included demographic information as well as perceptions about the ACVS and diversity, equity, and inclusion (DEI). Responses were quantitatively and qualitatively analyzed.
RESULTS
The survey response rate was 34% (737/2,199). The median age category among respondents was 45 to 54. The median years in practice as a diplomate was 11 to 15. The majority of respondents identified as white/Caucasian and heterosexual, with male and female respondents being similarly represented. Most respondents identified English as their first language. Few considered themselves first-generation college graduates or identified as disabled. Many respondents considered DEI to be an important initiative to promote in the ACVS.
CLINICAL RELEVANCE
Findings suggested that the majority of ACVS respondents are supportive of DEI efforts. This study also serves as an objective analysis that can be reassessed in the future to determine the success of such initiatives.
Introduction
Veterinary medicine is considered one of the least diverse professions in the US.1 According to the Association of American Veterinary Medical Colleges (AAVMC), diversity in veterinary medicine means having individuals in the profession of different gender, gender identity, sexual orientation, socioeconomic status, cultural background, language, cognitive style, nationality, age, physical abilities, religious beliefs, political beliefs, and other forms of differences, both visible and invisible. Multiple benefits have been attributed to diversity within the health professions, including increased patient satisfaction; new perspectives, which can lead to advanced innovation; and increases in fiscal performance and budget management.2–4 Additionally, individuals of racial and ethnic backgrounds considered underrepresented in medicine are more likely to work in underserved communities and mentor trainees of underrepresented backgrounds.5
Evidence indicates that to make improvements in diversity, equity, and inclusion (DEI), benchmarking efforts are necessary.6 Surveys are 1 tool for assessing DEI efforts that support a culture of accountability, self-assessment, and continuous improvement.7 The AAVMC compiles demographic data from a survey administered to internal members every fall. These data have demonstrated moderate advances in representation of certain groups within the veterinary student population, but no data were collected on veterinarians in specialty practice.8 Anecdotal evidence suggests minimal diversity within specialty fields, and it is unclear whether any veterinary specialty college has documented its membership demographics.
The purpose of this research was to gather demographic information on diplomates of the American College of Veterinary Surgeons (ACVS) and to summarize perspectives on the importance of DEI initiatives. The importance of DEI has been shown to be key to providing the highest quality of care, fostering unique perspectives, and reducing disparities in the medical care provided to human patient populations.7 To achieve similar progress, barriers to increasing diversity must be identified. By assessing the current state of diversity in the ACVS as well as diplomates’ perceptions related to DEI, members of the profession can work to break down barriers that prevent individuals from gaining access to the field.
Methods
Study population
The ACVS demographic survey was made available to all current ACVS member diplomates (n = 2,199) from August 25 to September 9, 2021. The Institutional Review Board provided a waiver of informed consent.
Survey development
In 2020, the ACVS formed a committee to ensure its commitment to DEI within the college. The ACVS Board of Regents, the ACVS diplomate–elected governing body of the college, charged the DEI Committee to examine policies of ACVS and consider bias and barriers that underrepresented individuals or groups face by being a member of ACVS. This included exploring attitudes related to how individuals are treated. To address this task, the DEI committee chose to begin by objectively measuring which groups were underrepresented and by asking diplomates their views related to DEI. From this, the ACVS DEI committee developed and ranked a set of questions that used basic demographic items provided by the AAVMC as an initial template and were intended to represent a current baseline for demographic data for ACVS diplomates.
Survey
A 14-item survey was designed by the ACVS committee on DEI to obtain objective information about respondent demographics including age, number of years as an ACVS diplomate, race, gender identity, sexual orientation, disability, language, and first-generation college-student status. To explore ACVS members’ perspectives related to DEI, 3 additional questions were included. One Likert-type question asked whether the respondent believed that the ACVS values diversity, equity, inclusion, and belonging. Another prompt asked respondents whether they consider DEI an important initiative to promote (yes/no), with an option to add comments. A final question asked, “What area and/or issues would you like to see the committee address?” The survey was administered via an online platform, and all responses were anonymous. Data were imported into SPSS Statistics, version 28 (IBM), for analysis.
Statistical analysis
Descriptive statistics were computed for all items. Inferential statistical analysis was computed using SPSS, version 28 (IBM), to determine relationships between variables, including χ2, Mann-Whitney, and Kruskal Wallis. Values of P < .05 were considered significant.
Qualitative analysis of open-ended responses
A qualitative content analysis was performed including 3 rounds of coding. For the first round, 2 raters (LMG and AAK) independently read each open-ended response for both prompts, noting consistent keywords and phrases. The coders then met to discuss their independently developed inductive codes. Once the list of codes was agreed upon, the raters coded 10% of the responses together with discussion related to each code (second round of coding). This allowed for further clarification related to each code. For the third round of coding, a subset of responses (20%) was independently coded to determine the inter-rater reliability using Cohen κ to ensure an acceptable level of agreement (> 70%). The remaining responses were coded independently.
Results
Respondents
Thirty-four percent (737/2,199) of ACVS diplomates completed the survey. Additional comments were provided by 114 of 737 (16%) respondents to the question “Do you consider DEI an important initiative to promote in the ACVS?” and 201 of 737 (27%) respondents provided comments to the question “What areas would you like to see the committee address?”
Personal demographics
The survey respondents’ ages ranged from 25 to 75 years old, with the median age category of 45 to 54 years. Of the respondents, 78 of 737 (10.5%) were between the ages of 25 and 34, 222 of 737 (30%) were between 35 and 44, 181 of 737 (24.5%) were between 45 and 54, 160 of 737 (22%) were between 55 and 64, 70 of 737 (9.5%) were between 65 and 74, 22 of 737 (3%) were 75 or older, and 4 of 737 (0.5%) declined to specify an age. Respondents’ years in practice as a diplomate ranged from < 5 to > 20, with median years of diplomate status in the 11 to 15 years category. Responses indicated that 136 of 737 (18%) respondents have practiced < 5 years, 145 of 737 (20%) have practiced between 5 and 10 years, 107 of 737 (14.5%) have practiced between 11 and 15 years, 78 of 737 (11%) have practiced between 16 and 20 years, 267 of 737 (36%) have practiced > 20 years, and 4 of 737 (0.5%) declined to disclose their number of years in practice.
Respondents were asked to identify their race/ethnicity. The vast majority of respondents identified as white/Caucasian, making up 655 of 737 (89%) responses. Of the remaining respondents, 30 of 737 (4%) identified as Hispanic/Latinx, 24 of 737 (3%) as Asian, 15 of 737 (2%) as African American/Black, 7 of 737 (1%) as Indigenous American/Native Alaskan, 7 of 737 (1%) as Middle Eastern, and 1 of 737 (0.14%) as Native Hawaiian/Pacific Islander; 10 of 737 (1.36%) self-identified an identity not listed, and 14 of 737 (2%) declined to specify a racial/ethnic identity.
Respondents were asked to identify their gender identity. Of these, 728 of 737 (99%) responded to the question. A majority (367/728 [50.4%]) identified as men, 347 of 728 (47.5%) identified as women, 3 of 728 (0.41%) identified as nonbinary, 2 of 728 identified as a gender not listed, and 9 of 728 (1%) declined to say. When specifically asked to identify as transgender, 710 of 728 (97.5%) responded no, 3 of 728 (0.4%) responded yes, and 15 of 728 (2%) declined to say. When asked to describe their sexual orientation, the majority of respondents (657/728 [90%]) identified as heterosexual. Of the remaining respondents, 15 of 728 (2%) identified as bisexual, 13 of 728 (2%) as lesbian, 8 of 728 (1%) as gay, 4 of 728 (0.55%) as questioning, 3 of 728 (0.4%) as queer, and 2 of 728 (0.27%) as asexual; 8 of 728 (1%) identified with a sexual identity not listed, and 18 of 728 (2.5%) declined to say.
Respondents were asked whether they had been diagnosed with a disability. This question was answered by 723 of 737 (98%) respondents. The majority of respondents (653/723 [90%]) had not been diagnosed with a disability. The remaining respondents (70/723 [10%]) identified with a disability. Respondents were asked their first language; 723 of 737 (98%) responses were received, with the majority (628/723 [87%]) identifying English as their first language. Of the remaining respondents, 95 of 723 (13%) listed an alternate first language. When respondents were asked whether they considered themselves first-generation college graduates, 723 of 737 responses were received, with the majority (517/723 [72%]) stating no and 206 of 723 (28%) stating yes. When respondents were asked whether they had ever served or were currently serving in the military, 691 of 723 (96%) stated no and 32 of 723 (4%) stated yes.
Assessment of DEI-related questions
Almost half of respondents (313/714 [43.8%]) agreed that the ACVS values diversity, equity, inclusion, and belonging, with only 10.8% (77/714) disagreeing. The remaining 45.4% (324/714) neither agree nor disagree. In response to the prompt “Do you consider DEI an important initiative to promote in the ACVS?” the majority of respondents (588/714 [82%]) did consider DEI an important initiative to promote in the ACVS.
Of the 2 open-ended prompts, 114 of 737 participants responded to the first open-ended prompt inviting comments in response to the question “Do you consider DEI an important initiative to promote?” and 201 of 737 participants responded to the second open-ended question, “What areas would you like the committee to address?”
Themes were inductively developed and used to code the statements associated with the open-ended questions (Tables 1 and 2).
List of themes identified from the open-ended question “Do you consider DEI an important initiative to promote in the ACVS?”
| Assigned No. | Theme |
|---|---|
| 1 | Credentials, qualifications, knowledge, and merit should be the focus |
| 2 | Policies (quotas) prioritize DEI over individual qualifications |
| 3 | No evidence that lack of diversity is a current problem |
| 4 | DEI focus is outside the scope of ACVS (focus on training surgeons) |
| 5 | In support of ACVS DEI initiatives and importance of creating pipelines |
| 6 | The emphasis should be on gender equity and inclusion but not diversity |
| 7 | Debt more important |
ACVS = American College of Veterinary Surgeons. DEI = Diversity, equity, and inclusion.
List of themes identified from the open-ended question “What area and/or issues would you like to see the committee address?”
| Assigned No. | Theme |
|---|---|
| 1 | Gender inequities, sexism, misogyny, including family and parental responsibilities and salary inequities |
| 2 | Workplace climate and culture |
| 2a | Work-life balance |
| 2b | Bullying |
| 2c | Mentorship |
| 2d | Importance of supportive, inclusive environment |
| 2e | Mental health |
| 3 | No evidence that lack of diversity is currently a problem |
| 4 | DEI focus is outside the scope; scope is training surgeons |
| 5 | DEI, pipeline issue, and addressing bias in residency selection process |
| 6 | Accommodating disabilities |
| 7 | Training, presentations, and seminars related to DEI |
Analysis of this qualitative data suggested that 25% (14/114) of respondents who commented think that credentials, qualifications, knowledge, and merit should be the focus even if they stated that DEI is important to promote. In particular, there is some concern that a focus on DEI could lead to policies (quotas) that prioritize DEI over individual qualifications (14/114 [12%]). Thirty-six percent (31/114) of respondents did not consider DEI an important initiative to promote either because there is no evidence that lack of diversity is currently a problem (14% [16/114]) or because a DEI focus is outside the scope of the ACVS, which should instead focus on the mission of training and supporting surgeons (22% [25/114]). Twenty-four percent (28/114) of respondents stated that they are in support of DEI initiatives, particularly the creation of pipelines to target underrepresented populations. Twelve percent (14/114) of respondents expressed support for an emphasis on gender identity equity and inclusion, but not diversity. Finally, a small percentage (9/114 [8%]) of respondents thought debt and other issues were more important than DEI.
Relationship between demographic factors and perspectives on DEI
Males were more likely than females to say that DEI is important to promote (P < .001). A significant relationship was also found between age and number of years in practice as a diplomate and views related to DEI. Specifically, younger diplomates were more likely than older diplomates to say that DEI is important to promote (P < .001; Figure 1). Respondents that identified as first-generation college students were also less likely to consider DEI an important initiative to promote (P = .008); however, these individuals were predominantly individuals of increased age (P < .001). It is important to note that gender and age were also related in that male respondents were younger with fewer years in practice as a diplomate (P < .001). Of note, our total sample skewed younger, with only 13% being 65+ and males accounting for only 4% of this age group.
Graph of the number of respondents within each age group that responded for or against support of the American College of Veterinary Surgeons (ACVS) promoting diversity, equity, and inclusion (DEI) initiatives. Younger diplomates were more likely than older diplomates to say that DEI is important to promote (P < .001).
Citation: Journal of the American Veterinary Medical Association 261, 12; 10.2460/javma.23.06.0310
Respondents who indicated that DEI is important to promote were more likely to support DEI initiatives and pipelines (P < .001). Respondents who indicated that DEI is not important to promote were more likely to say that credentials, qualifications, knowledge, and merit should be the main focus of the specialty college (P = .035; Figure 2) or that it is outside the scope of the ACVS (P < .001; Figure 3).
Graph of the relationship between whether respondents believed that DEI was important to promote and whether they believed that credentials, qualifications, knowledge, and merit should be the focus. Respondents who indicated that DEI is not important to promote were more likely to say that credentials, qualifications, knowledge, and merit should be the focus (P = .035). Bar with asterisk indicates statistical significance.
Citation: Journal of the American Veterinary Medical Association 261, 12; 10.2460/javma.23.06.0310
Relationship between whether respondents believed that DEI was important to promote and whether they believed that it was outside the scope of the ACVS. Respondents who indicated that DEI is not important to promote were more likely to say that it is outside the scope of the ACVS (P < .001). Bar with asterisk indicates statistical significance.
Citation: Journal of the American Veterinary Medical Association 261, 12; 10.2460/javma.23.06.0310
ACVS future directions
In terms of the prompt “What areas would you like the committee to address?” 201 of 714 (28%) provided responses. Thirty-three percent (67/201) suggested that the ACVS address issues related to workplace culture and climate, including promoting a supportive/inclusive environment (31), encouraging professional mentorship (12), addressing workplace bullying (10), and promoting work-life balance (10). An additional 33% (n = 67) suggested that the ACVS should focus on gender inequities, sexism, and misogyny, including family and parental responsibilities and salary inequities. Twenty-seven percent (n = 55) of responses indicated that the ACVS should focus on promoting pipelines and addressing bias in the residency selection process.
Discussion
These results provide information related to the current demographics of ACVS membership and their perspectives on DEI. While we acknowledge that conclusions must be interpreted cautiously given our response rate, the demographics of our sample (Table 3) are fairly consistent with a 2015 ACVS survey on employment, professional success, and personal life.9 The results of this survey illustrate that a majority of respondents think DEI is important to promote, particularly among younger diplomates. More specifically, there is support for pipelines, gender equity, and targeted efforts to address workplace culture and climate. Those who do not think DEI is important to promote questioned whether lack of diversity is a problem, cited concerns about DEI being outside the scope of the mission of ACVS, and specified that credentials and merit should be the focus.
Results for demographic information obtained from 737 survey respondents.
| Gender | Race/ethnicity | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| White/Caucasian | Hispanic/Latinx | Asian | African American/Black | Indigenous American/Native Alaskan | Middle Eastern | Native Hawaiian/Pacific Islander | Identity not listed or declined to say | Total | |
| Male | 314 | 24 | 11 | 7 | 4 | 3 | 1 | 3 | 367 |
| Female | 312 | 7 | 13 | 6 | 1* | 3 + 1* | 0 | 5 | 347 |
| Non-binary | 1 | 0 | 0 | 2 | 1* | 0 | 0 | 0 | 3 |
| Gender not listed or declined to say | 7 | 0 | 0 | 0 | 1 | 0 | 0 | 12 | 20 |
| Total | 634 | 31 | 24 | 15 | 7 | 7 | 1 | 20 | 737 |
*Indicates an individual who identified as more than 1 race/ethnicity.
While most respondents feel that DEI is important to promote, only about 45% agree that the ACVS values DEI, suggesting that a greater emphasis on DEI within the ACVS may be welcomed. Two high-impact DEI implementation strategies that would be appropriate for any organization whose members are supportive of DEI are “including DEI as part of the mission, vision, or internal rules” and dedicated working groups or committees.10 Since over 80% of diplomates who responded to the survey consider DEI important to promote, it would seem that members would support the ACVS adopting these 2 high-impact interventions. This would demonstrate the ACVS’s commitment to DEI initiatives and promote information-sharing with members who may not understand or value DEI as part of the mission of the ACVS. Beyond including DEI as part of the mission and vision, the ACVS could set specific objectives related to DEI that are shared with members and made public to enhance accountability and follow-through as suggested by Kayingo et al.7 For example, the American College of Veterinary Emergency Critical Care formed a DEI committee in 2020 with several accomplishments to date, including creating a “toolkit” of resources, access to training, and the formation of a mentorship committee.11 Specifically, targeted training programs and webinars can positively impact awareness and understanding of DEI issues facing underrepresented and stigmatized groups, and this would be applicable to any professional organization. The ACVS, as an organization, demonstrated their commitment to DEI by forming a DEI committee and supporting the distribution of this demographic survey. However, as demonstrated by other aligned professions, including human medicine, formalizing DEI as part of an organization’s mission, coupled with presentations and seminars that educate about the many benefits of diversity, is beneficial to both those who would like to see greater promotion of DEI as well as those who may need clarity about the current lack of diversity and the role of DEI as part of an organization’s broader vision.
Although only a minority of respondents indicated that DEI is not important to promote because “lack of diversity is not a problem,” results from this survey suggested the opposite, particularly with respect to race, ethnicity, and sexual orientation. Moreover, this is at odds with prior research indicating discrimination stemming from gender identity, race, ethnicity, and sexual orientation and subsequent mental health issues.10 Somewhat concerning is the notion that DEI is not important to promote because credentials and merit should be the focus. This finding suggests that valuing and emphasizing DEI is somehow considered to be at odds with selecting and training highly qualified veterinary surgeons. It is important to provide education that debunks this myth. In fact, qualified applicants from underrepresented groups may not be applying to residency programs because of a pipeline deficiency. Previous research points to gender segregation, in particular, as related to the decision to apply for residency programs, thus supporting the importance of targeted recruitment and pipeline efforts.12 Additionally, a more diverse pool of veterinary instructors has been found to be a predictor for interest in graduate programs, further supporting the focus on pipelines. A shifting paradigm around DEI should include rewarding the labor that accompanies this additional service and mentoring.13 Furthermore, in contrast to the notion that DEI initiatives lower the quality of trainees or have the potential to decrease the quality of medical practice, multiple studies14,15 in human medicine have demonstrated that the inclusion of individuals with backgrounds underrepresented in medicine provides benefits to patient care and the quality of healthcare administered, in addition to increasing the breadth of medical research conducted by bringing alternative perspectives and promoting creativity.
The main limitation to this study was sample size and skewness such that the sample skewed younger, with males being overrepresented in the age group 44 and under. Although the response rate was considered good for a survey, the complete representation of diplomates remains unknown. This particularly impacts respondents from underrepresented groups, as their answers became significantly underpowered. Another fundamental limitation is response bias. It is possible that respondents already have strong views related to DEI. As a result, there is a possibility that this sample does not accurately represent the population of ACVS diplomates, thus skewing the results of both the quantitative and qualitative data. Given the important information gleaned from this study, it is our hope that subsequent surveys will obtain a greater response rate to accurately represent the population of ACVS diplomates. Another limitation of the study was the length of the survey. The number of questions and possible answers were selected to keep the survey short and easy to complete. However, this may have limited our ability to obtain a complete picture as to the diversity of our study population. A fourth limitation could be respondents’ subjective interpretations of “diversity, equity, and inclusion” since no specific definition/description was provided. Despite these limitations, it is clear from the survey that the majority of respondents do believe that DEI is an important initiative to pursue, and many provided insights into areas the ACVS can target for improvement. It is important that future surveys be conducted objectively to measure the outcomes of future DEI initiatives.
In summary, despite strong support for DEI from most respondents, some diplomates stated or insinuated that initiatives to increase diversity threaten the quality of candidates and future surgeons and found this to be of particular concern. Further, there appeared to be concerns related to gender inequalities, sexism, and misogyny within our specialty. Targeted efforts to include DEI as part of the mission of the ACVS, as well as efforts to address workplace culture and climate and pipelines, should be emphasized.
Acknowledgments
The authors would like to recognize the contributions of the American College of Veterinary Surgeons (ACVS) Board of Regents and the members of the ACVS Diversity, Equity, and Inclusion Committee who helped design the survey questions and for the critical discussions of survey responses. The members of the ACVS Diversity, Equity, and Inclusion Committee include Dr. Laurie Goodrich, Sarah Donnelly (ACVS staff liaison), Dr. Courtney Campbell, Dr. Po-Yen Chou, Dr. Karen Hassan, Dr. Caroline Constant, Dr. Rebecca Essig, and Dr. Javier Gallegos.
Disclosures
Dr. Gonzalez is a member of the Journal of the American Veterinary Medical Association (JAVMA) scientific review board. She declares that she had no role in the editorial direction of this manuscript. No AI-assisted technologies were used in the generation of this manuscript.
Funding
The authors have nothing to disclose.
References
- 1.↑
Labor force characteristics by race and ethnicity, 2021. US Bureau of Labor Statistics. January 2023. https://www.bls.gov
- 2.↑
Gill G, Singh B. Where do deans of veterinary medicine in the United States and Canada come from? Can Vet J. 2020;61(11):1187-1196.
- 3.
Ayman R, Korabik K. Leadership: why gender and culture matter. Am Psychol. 2010;65(3):157-170. doi:10.1037/a0018806
- 4.↑
Beer J. Diversity in leadership. Perspect Pol Pract Higher Educ. 2015;19(2):40-42. doi:10.1080/13603108.2015.1021402
- 5.↑
Rahal HK, Tabibian JH, Issaka RB, et al. Diversity, equity, and inclusion in gastroenterology and hepatology: a survey of where we stand. Hepatology. 2022;76(6):1825-1835. doi:10.1002/hep.32757
- 6.↑
Chilazi S, Bohnet I. How to best use data to meet your DE&I goals. December 3, 2020. https://hbr.org/2020/12/how-to-best-use-data-to-meet-your-dei-goals
- 7.↑
Kayingo G, Bradley-Guidry C, Burwell N, Suzuki S, Dorough R, Bester V. Assessing and benchmarking equity, diversity, and inclusion in healthcare professions. JAAPA. 2022;35(11):51-54. doi:10.1097/01.JAA.0000885184.50730.94
- 8.↑
Annual Data Report, 2021-2022. American Association of Veterinary Medical Colleges. 2022. Accessed July 13, 2023. https://www.aavmc.org/about-aavmc/public-data
- 9.↑
Morello SL, Colopy SA, Bruckner K, Buhr KA. Demographics, measures of professional achievement, and gender differences for diplomates of the American College of Veterinary Surgeons in 2015. J Am Vet Med Assoc. 2019;255(11):1270-1282. doi:10.2460/javma.255.11.1270
- 10.↑
Timmenga FSL, Jansen W, Turner PV, De Briyne N. Mental well-being and diversity, equity, and inclusiveness in the veterinary profession: pathways to a more resilient profession. Front Vet Sci. 2022;9:888189. doi:10.3389/fvets.2022.888189
- 11.↑
Odunayo A, Alwood A, Asokan V, et al. Our quest for creating a space that is welcoming to all: a commentary from the American College of Veterinary Emergency and Critical Care Diversity, Equity, and Inclusion Committee. J Vet Emerg Crit Care (San Antonio). 2022;32(2):165-167. doi:10.1111/vec.13190
- 12.↑
Morello SL, Genovese J, Pankowski A, Sweet EA, Hetzel SJ. Occupational segregation by gender in veterinary specialties: who we are choosing, or who is choosing us. Vet Surg. 2021;50(6):1191-1200. doi:10.1111/vsu.13676
- 13.↑
Milstein MS, Gilbertson MLJ, Bernstein LA, Hsue W. Integrating the Multicultural Veterinary Medical Association actionables into diversity, equity, and inclusion curricula in United States veterinary colleges. J Am Vet Med Assoc. 2022;260(10):1145-1152. doi:10.2460/javma.21.10.0459
- 14.↑
Carethers JM, Quezada SM, Carr RM, Day LW. Diversity within US gastroenterology physician practices: the pipeline, cultural competencies, and gastroenterology societies approaches. Gastroenterology. 2019;156(4):829-833. doi:10.1053/j.gastro.2018.10.056
- 15.↑
Moy E, Bartman BA. Physician race and care of minority and medically indigent patients. JAMA. 1995;273(19):1515-1520. doi:10.1001/jama.1995.03520430051038
