Examining the Presence, Consequences, and Reduction of Implicit Bias in Health Care: A Narrative Review

Racial bias in perceptions of children's pain

Across eight experiments, we investigated whether adult perceivers (both lay perceivers and elementary school teachers) evaluate children's pain differently depending on the child's race. We found evidence that adults varying in racial and ethnic identities (but primarily White) believed 4- to 6-year-old Black children felt less pain than 4- to 6-year-old White children (Experiments 1-7), and this effect was not moderated by child sex (Experiments 6-7). We also examined perceptions of life hardship as a mediator of this race-to-pain effect, finding that adults evaluated Black children as having lived harder lives and thus as feeling less pain than White children (Experiments 1-3). Finally, we examined downstream consequences for hypothetical treatment recommendations among samples of both lay perceivers and elementary school teachers. We found that adults' perceptions of pain sensitivity were linked with hypothetical pain treatment decisions (Experiments 5a-7). Thus, we consistently observed that adults' race-based pain stereotypes biased evaluations of 4- to 6-year-old children's pain and may influence pain care. This racial bias in evaluations of young children's pain has implications for psychological theory and equitable treatment of children's pain. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

A scoping review of research on potential impact of implicit bias in healthcare settings for children with acquired brain injuries

PURPOSE/OBJECTIVE

Acquired brain injury (ABI) is a leading cause of disability in children and adolescents. Implicit biases within pediatric ABI healthcare settings may exert negative effects on clinical interactions and medical decision-making processes. This study aimed to conduct a scoping review of current research that examines the potential impact of implicit biases in such healthcare settings for children with ABI.

RESEARCH METHOD/DESIGN

Following PRISMA-ScR guidelines, a search among five databases (CINAHL, Cochrane CENTRAL, PubMed, PsycArticles, and PsycInfo) was conducted, followed by abstract/full-text screening and data extraction. Main characteristics of the included studies, including research design, relevance to implicit biases, and public health impact were synthesized. The risk of bias of included studies was assessed.

RESULTS

Out of the 203 articles returned from the literature search, a total of three studies met the inclusion criteria for the present review. All studies examined the relevance of racial/ethnic biases for evaluating abusive head trauma or nonaccidental trauma. The included studies had an overall unclear to low risk of biases.

CONCLUSIONS/IMPLICATIONS

This scoping review identified scarce but emerging evidence of the presence and detrimental impact of potential implicit biases on the access and quality of care received by children with ABI. More research is needed to examine the causes, process mechanisms, and consequences of implicit biases in pediatric ABI healthcare settings. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

LGBTQ+ Microaggressions in Health Care: Piloting an Observation Framework in a Standardized Patient Assessment

Microaggressions are subtle derogatory behaviors that unintentionally communicate hostility toward marginalized social groups. This article describes the preliminarily validation of a framework for observing LGBTQ+ microaggressions in health care, which can lead to distrust and disengagement from the healthcare system. Coders used the framework to observe microaggressions in video-recorded clinical-skills assessments with medical students who elicited health histories from standardized patients. Microaggression classifications were reviewed to determine construct reliability and the presence/absence among eight framework categories. Among 177 encounters with sexual and gender minority standardized patients, heteronormative/cisnormative language and assumptions occurred in the largest proportion of encounters (85.3%). Only identity-based referrals decreased significantly after a clinical skills intervention (20.0% to 4.9%, p = .01). These outcomes show that LGBTQ+ healthcare microaggressions are pervasive and will likely require nuanced training to address them. This groundwork can also be used to develop scales for patients and observers to identify microaggressions and assess perceived impact.

Initial evidence of reliability and validity of an implicit association test assessing attitudes toward individuals who use substances

Background: Substance use disorders (SUDs) are stigmatized conditions, with individual biases driving poor health outcomes. There are surprisingly few validated measures of bias or stigma toward individuals who use substances. Bias can be classified as explicit (self-report) or implicit (behaviorally based).Objectives: The goal of the present study was to establish preliminary indices of reliability and validity of an implicit association test (IAT) designed to measure implicit bias toward individuals who use substances.Methods: A large United States-based, crowd-sourced sample (n = 394, 51.5% male, 45.4% female, 2.5% nonbinary) completed the IAT and a small battery of survey instruments that assessed social distance to mental illness (including heroin use), attitude toward and perceived controllability of injection drug use, perception of public stigma, and social desirability.Results: Nearly all (92%; n = 363) scores on the IAT indicated greater negative than positive attitudes toward those who use substances. Spearman-Brown corrected split-half reliability on the IAT scores was excellent, r = .953. Controlling for social desirability, IAT scores positively correlated with all included measures pertaining to substance use as well as social distance for heroin and schizophrenia (but not diabetes). A principal component analysis resulted in two interpretable components representing disapproval (perceived controllability and negative attitudes) and perceived stigma (social stigma and social distance). Scores on the IAT positively correlated to scores on both components, again, controlling for social desirability.Conclusion: These results provide compelling preliminary evidence of validity of an IAT designed to measure bias toward individuals who use substances.

A scoping review to identify and organize literature trends of bias research within medical student and resident education

BACKGROUND

Physician bias refers to the unconscious negative perceptions that physicians have of patients or their conditions. Medical schools and residency programs often incorporate training to reduce biases among their trainees. In order to assess trends and organize available literature, we conducted a scoping review with a goal to categorize different biases that are studied within medical student (MS), resident (Res) and mixed populations (MS and Res). We also characterized these studies based on their research goal as either documenting evidence of bias (EOB), bias intervention (BI) or both. These findings will provide data which can be used to identify gaps and inform future work across these criteria.

METHODS

Online databases (PubMed, PsycINFO, WebofScience) were searched for articles published between 1980 and 2021. All references were imported into Covidence for independent screening against inclusion criteria. Conflicts were resolved by deliberation. Studies were sorted by goal: 'evidence of bias' and/or 'bias intervention', and by population (MS or Res or mixed) andinto descriptive categories of bias.

RESULTS

Of the initial 806 unique papers identified, a total of 139 articles fit the inclusion criteria for data extraction. The included studies were sorted into 11 categories of bias and showed that bias against race/ethnicity, specific diseases/conditions, and weight were the most researched topics. Of the studies included, there was a higher ratio of EOB:BI studies at the MS level. While at the Res level, a lower ratio of EOB:BI was found.

CONCLUSIONS

This study will be of interest to institutions, program directors and medical educators who wish to specifically address a category of bias and identify where there is a dearth of research. This study also underscores the need to introduce bias interventions at the MS level.

Racism and access to maternal health care among garo indigenous women in Bangladesh: A qualitative descriptive study

Racism as social determinant of health significantly affects Indigenous women's maternal healthcare access. This study uses Jones' 'Three Levels of Racism' theory and an intersectional lens to explore how racism shapes the experience of maternal health care access among Garo Indigenous women in Bangladesh. Semi-structured interviews were conducted with 24 women of diverse backgrounds and pregnancy statuses using snowball sampling. Thematic analysis, incorporating inductive and deductive approaches, was employed for data analysis. The findings reveal a significant deviation from Jones' theory regarding the level of internalized racism within the specific context of Garo Indigenous women's experiences. Jones' theory usually focuses on how racism is internalized due to institutional and personally-mediated factors. On the contrary, this study uncovers a unique theme: 'women agency.' This theme emerges as a robust response among the Garo Indigenous women to their encounters with institutional and personally-mediated racism, highlighting their cultural resistance and resilience. The findings suggest that the complex relationship between these two forms of racism contributes to the strengthening of agency among Garo Indigenous women. Their agency stems from avoiding hospitals that disrespect their culture, manifesting their cultural resistance practice against the encountered racism at the institutional and relational levels. To increase biomedical healthcare access among Garo Indigenous women, it is recommended to address racism through intercultural competency training with the 'cultural safety' 'cultural humility' approach. This approach would foster inclusivity and empowerment, recognizing the agency of Garo women in healthcare decisions. Additionally, it would facilitate constructive dialogues between clinicians and Garo Indigenous women, acknowledging the shared experiences of racism within the latter group.

Using Simulation to Teach Learners in Health Care Behavioral Skills Related to Diversity, Equity, and Inclusion: A Scoping Review

SUMMARY STATEMENT

Bias is commonplace in the health care environment and can negatively impact patients and their health outcomes. Simulation has long been shown to be an effective teaching tool for communication skills in health care, but it has rarely been used to deliver concrete behavioral skills that address issues of diversity, equity, and inclusion (DEI). This scoping review examines 23 published articles surrounding the use of simulation in health care education to impart behavioral skills that reduce bias and promote DEI. Included articles described various behavioral skills including communication, history-taking, and system/community-level advocacy. The most commonly used simulation modality to teach these skills included the use of simulated participants (16 articles, 70%). The main DEI topics addressed in the trainings included sexual orientation/gender identity, language, and culture/ethnicity. Based on findings from this review, the authors suggest recommendations for educators who are considering teaching DEI-related skills through simulation.

Implicit Racial Bias, Health Care Provider Attitudes, and Perceptions of Health Care Quality Among African American College Students in Georgia, USA

OBJECTIVE

Due to racism, over 20% of African Americans, including college students in Georgia, receive poor quality health care. Consequently, most students are reluctant to utilize health care services in the state. This study examined biased racial attitudes of health care providers in Georgia, and African American Georgia State University (GSU) School of Public Health (SPH) students' perceptions of the quality of health care they receive from providers, the effects of such care, and student recommendations for the way forward.

DESIGN

A mixed-methods cross-sectional design was used to collect data from 63 students across six domains using Qualtrics.

RESULTS

Provider brushes off patient concerns when providing medical care (29.9%), stereotyping (26.9%), and the lack of communication during medical care (25.4%) were the three main implicit racial attitudes identified by GSU SPH students. Owing to the poor quality of care they receive from their health care providers, some students (28.4%) are reluctant to utilize health care services, distrust doctors that are not from their race (34.3%), do not adhere to treatment (19.4%), and prefer to use home remedies (28.4%) when ill. Students recommended cultural competency training, holding health care providers accountable for their actions, and increasing African American health care providers in Georgia as ways to address health care provider attitudes and quality of care.

CONCLUSION

Negative provider attitudes impact the health and health-seeking behavior of African American college students in Georgia. These attitudes must be eliminated so barriers to clinical participation are removed, and student health outcomes optimized.

Emerging Racial Differences in Heart Transplant Waitlist Outcomes for Patients on Temporary Mechanical Circulatory Support

Temporary mechanical circulatory support (tMCS) is increasingly used for patients awaiting heart transplantation. Although examples of systemic inequity in cardiac care have been described, biases in tMCS use are not well characterized. This study explores the racial disparities in tMCS use and waitlist outcomes. The United Network for Organ Sharing database was used to identify adults listed for first-time heart transplantation from 2015 to 2021. White and non-White patients on extracorporeal membrane oxygenation, intra-aortic balloon pump, or temporary left ventricular assist device were identified. Waitlist outcomes of mortality, transplantation, and delisting were analyzed by race using competing risks regression. The effect of the new heart allocation system was also assessed. A total of 16,811 patients were included in this study, with 10,377 self-identifying as White and 6,434 as non-White. White patients were more often male, privately ensured, and had less co-morbidities (p <0.05). tMCS use was found to be significantly higher in non-White patients (p <0.001). Among those on tMCS, non-White patients were more likely to be delisted because of illness (subhazard ratio 1.34 [1.09 to 1.63]) and less likely to die while on the waitlist (subhazard ratio 0.76 [0.61 to 0.93]). This disparity was not present before the implementation of the new heart allocation system. tMCS use was proportional to the risk factors identified in the non-White cohort. After the implementation of the new heart allocation system, White patients were more likely to die, whereas non-White patients were more likely to be delisted. Further work is needed to determine the causes of and potential solutions for disparities in the waitlist outcomes.

Challenges and Opportunities for Clinician Implicit Bias Training: Insights from Perinatal Care Stakeholders

Introduction

In an attempt to address health inequities, many U.S. states have considered or enacted legislation requiring antibias or implicit bias training (IBT) for health care providers. California's "Dignity in Pregnancy and Childbirth Act" requires that hospitals and alternative birthing centers provide IBT to perinatal clinicians with the goal of improving clinical outcomes for Black women and birthing people. However, there is as yet insufficient evidence to identify what IBT approaches, if any, achieve this goal. Engaging the experiences and insights of IBT stakeholders is a foundational step in informing nascent IBT policy, curricula, and implementation.

Methods

We conducted a multimethod community-based participatory research study with key stakeholders of California's IBT policy to identify key challenges and recommendations for effective clinician IBT. We used focus groups, in-depth interviews, combined inductive/deductive thematic analysis, and multiple techniques to promote rigor and validity. Participants were San Francisco Bay Area-based individuals who identified as Black or African American women with a recent hospital birth (n=20), and hospital-based perinatal clinicians (n=20).

Results

We identified numerous actionable challenges and recommendations regarding aspects of (1) state law; (2) IBT content and format; (3) health care facility IBT implementation; (4) health care facility environment; and (5) provider commitment and behaviors. Patient and clinician insights overlapped substantially. Many respondents felt IBT would improve outcomes only in combination with other antiracism interventions.

Health Equity Implications

These stakeholder insights offer policy-makers, health system leaders, and curriculum developers crucial guidance for the future development and implementation of clinician antibias interventions.

Stratifying Risk of Nonadherence in Lingual Strengthening Dysphagia Rehabilitation

PURPOSE

Exercise-based treatments may improve swallowing safety and efficiency; yet, it is not clearly understood which factors predict nonadherence to recommended treatment protocols. The aim of this study was to construct an algorithm for stratifying risk of nonadherence to a lingual strengthening dysphagia treatment program.

METHOD

Using recursive partitioning, we created a classification tree built from a pool of sociodemographic, clinical, and functional status indicators to identify risk groups for nonadherence to an intensive lingual strengthening treatment program. Nonadherence, or noncompletion, was defined as not completing two or more follow-up sessions or a final session within 84 days.

RESULTS

The study cohort consisted of 243 Veterans enrolled in the Intensive Dysphagia Treatment program across six sites from January 2012 to August 2019. The overall rate of nonadherence in this cohort was 38%. The classification tree demonstrated good discriminate validity (C-statistic = 0.74) and contained eight groups from five variables: primary diagnosis, marital status, Penetration-Aspiration Scale (PAS) severity score, race/ethnicity, and age. Nonadherence risk was categorized as high (range: 69%-77%), intermediate (27%-33%), and low risk (≤ 13%-22%).

CONCLUSIONS

This study identified distinct risk groups for nonadherence to lingual strengthening dysphagia rehabilitation. Additional research is necessary to understand how these factors may drive nonadherence. With external validation and refinement through prospective studies, a clinically relevant risk stratification tool can be developed to identify patients who may be at high risk for nonadherence and provide targeted patient support to mitigate risk and provide for unmet needs.

Disparities in Lupus and the Role of Social Determinants of Health: Current State of Knowledge and Directions for Future Research

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease. The complex relationships between race and ethnicity and social determinants of health (SDOH) in influencing SLE and its course are increasingly appreciated. Multiple SDOH have been strongly associated with lupus incidence and outcomes and contribute to health disparities in lupus. Measures of socioeconomic status, including economic instability, poverty, unemployment, and food insecurity, as well as features of the neighborhood and built environment, including lack of safe and affordable housing, crime, stress, racial segregation, and discrimination, are associated with race and ethnicity in the US and are risk factors for poor outcomes in lupus. In this scientific statement, we aimed to summarize current evidence on the role of SDOH in relation to racial and ethnic disparities in SLE and SLE outcomes, primarily as experienced in the U.S. Lupus Foundation of America's Health Disparities Advisory Panel, comprising 10 health disparity experts, including academic researchers and patients, who met 12 times over the course of 18 months in assembling and reviewing the data for this study. Sources included articles published from 2011 to 2023 in PubMed, Centers for Disease Control and Prevention data, and bibliographies and recommendations. Search terms included lupus, race, ethnicity, and SDOH domains. Data were extracted and synthesized into this scientific statement. Poorer neighborhoods correlate with increased damage, reduced care, and stress-induced lupus flares. Large disparities in health care affordability, accessibility, and acceptability exist in the US, varying by region, insurance status, and racial and minority groups. Preliminary interventions targeted social support, depression, and shared-decision-making, but more research and intervention implementation and evaluation are needed. Disparities in lupus across racial and ethnic groups in the US are driven by SDOH, some of which are more easily remediable than others. A multidimensional and multidisciplinary approach involving various stakeholder groups is needed to address these complex challenges, address these diminish disparities, and improve outcomes.

The ethics of infant and early childhood mental health practice

Ethics is concerned with the basis for moral judgments of "right" and "wrong" and is central to the clinical endeavor. Many clinicians integrate ethical estimations into their work without much conscious awareness. However, explicit use of ethical principles and frameworks can help navigate clinical decision-making when there is a sense of moral conflict or ambiguity about the "right" course of action. This article aims to highlight the key concepts and principles in clinical ethics as they apply to IECMH practice and stimulate a bigger conversation in the profession around how to support each other to maintain high ethical standards in working with young children and their families. Specifically, the authors consider the relevance of Beauchamp and Childress' four principles framework (respect for autonomy, beneficence, non-maleficence, and justice), and address some of the special ethical challenges in the field, namely, the vulnerability of the infant, the need for a competent workforce, caring for caregivers, and the problem of multiple patients. Finally, the role of infant rights is briefly explored, noting the significant interest and debate that has been generated by the publication of the World Association of Infant Mental Health's Position Paper on the Rights of Infants.

Potential influence of nurses' implicit racial bias on maternal mortality

Stark disparities persist in maternal mortality and perinatal outcomes for Black and other birthing people of color, such as Native Americans, and their newborns compared to White people in the United States. An increasing body of research describes the phenomenon of implicit racial bias among providers and how it may affect communication, treatment decisions, the patient care experience, and health outcomes. This synthesis of literature reviews and distills current research on the presence and influence of implicit racial bias among nurses as it may relate to maternal and pregnancy-related care and outcomes. In this paper, we also summarize what is known about implicit racial bias among other types of healthcare providers and interventions that can mitigate its effects, identify a gap in research, and recommend next steps for nurses and nurse researchers.

Disparities in the provision of perinatal care based on patient race in the United States

BACKGROUND

In the United States, there are significant health inequities in perinatal care. This study examined differences in perinatal care provided to women based on the birthing person's designated race, within a large and diverse cohort of women.

METHODS

This retrospective electronic medical record review identified patients receiving perinatal care within a large hospital system between January 2012 and September 2018 and examined associations between maternal designated race/ethnicity (Hispanic or non-Hispanic [NH] Black, Asian or White) and various provider treatment decisions.

RESULTS

The study sample (N = 7056) was comprised of 36% Hispanic, 34% NH White, 21% NH Black, and 4% NH Asian women, aged 29.7 ± 6.3 years; 53% of the sample had private insurance, and 45% had Medicaid. Few differences by race were seen in perinatal care based on guidelines or expert recommendations (nondiscretionary care). Discretionary care, however, varied by race: Compared with NH White women, NH Black women were less likely to receive a prenatal depression screen (OR 0.8 [95% CI: 0.7, 0.9]) and more likely to have a urine drug test when denying drug use (OR 1.6 [95% CI 1.3, 2.0]), whereas Hispanic (OR 0.6 [95% CI: 0.5, 0.8]) and NH Asian (0.4 [95% CI 0.2, 0.9]) women were less likely to have a urine drug test completed when denying drug use.

DISCUSSION

Perinatal care differs by maternal race/ethnicity, particularly when guidelines or expert recommendations are absent. Greater efforts need to be made to identify and mitigate providers' implicit and explicit biases; expanded professional guidelines may offer some protections against inequitable, discretionary care.

Relationships between the race implicit association test and other measures of implicit and explicit social cognition

Background

The race-based Implicit Association Test (IAT) was proposed to measure individual differences in implicit racial bias subsumed within social cognition. In recent years, researchers have debated the theoretical tenets underpinning the IAT, questioning whether performance on this task: (1) measures implicit attitudes that operate automatically outside of conscious awareness; (2) reflects individual differences in social cognition; and (3) can predict social behavior. One way to better address these research questions is to assess whether the race-IAT correlates with other implicit processes that are subsumed within social cognition.

Aims

The current study assessed whether the race-IAT was related to other commonly used individual difference measures of implicit (and explicit) social cognition. Experiment 1 assessed whether dissociable patterns of performance on the race-IAT were related to measures of implicit imitative tendencies, emotion recognition and perspective taking toward White task actors, as well as explicit measures of trait and state affective empathy and racial bias. Overcoming limitations of task conceptual correspondence, Experiment 2 assessed whether these latter tasks were sensitive in detecting racial biases by using both White and Black task actors and again examined their relationships with the race-IAT.

Method

In two lab-based experiments, 226 and 237 participants completed the race-IAT followed by an extensive battery of social cognition measures.

Results

Across both experiments, pro-White/anti-Black bias on the race-IAT was positively related to a pro-White bias on explicit measures of positive affective empathy. However, relationships between the race-IAT and implicit imitative tendencies, perspective taking, emotion recognition, and explicit trait and negative state affective empathy were statistically equivalent.

Conclusion

The race-IAT was consistently related to explicit measures of positive state affective empathy but not to other individual difference measures of implicit social cognition. These findings are discussed with regards to the theoretical underpinnings of the race-IAT as an individual difference measure of implicit social cognition, as well as alternative explanations relating to the reliability of social cognition measures and the various combinations of general-purpose (social and non-social) executive processes that underpin performance on these tasks.

Review of current 2SLGBTQIA+ inequities in the Canadian health care system

Gender identity and sexual orientation are determinants of health that can contribute to health inequities. In the 2SLGBTQIA+ community, belonging to a sexual and/or gender minority group leads to a higher risk of negative health outcomes such as depression, anxiety, and cancer, as well as maladaptive behaviors leading to poorer health outcomes such as substance abuse and risky sexual behavior. Empirical evidence suggests that inequities in terms of accessibility to health care, quality of care, inclusivity, and satisfaction of care, are pervasive and entrenched in the health care system. A better understanding of the current Canadian health care context for individuals of the 2SLGBTQIA+ community is imperative to inform public policy and develop sensitive public health interventions to make meaningful headway in reducing inequity. Our search strategy was Canadian-centric and aimed at highlighting the current state of 2SLGBTQIA+ health inequities in Canada. Discrimination, patient care and access to care, education and training of health care professionals, and crucial changes at the systemic and infrastructure levels have been identified as main themes in the literature. Furthermore, we describe health care-related disparities in the 2SLGBTQIA+ community, and present available resources and guidelines that can guide healthcare providers in narrowing the gap in inequities. Herein, the lack of training for both clinical and non-clinical staff has been identified as the most critical issue influencing health care systems. Researchers, educators, and practitioners should invest in health care professional training and future research should evaluate the effectiveness of interventions on staff attitudinal changes toward the 2SLGBTQIA+ community and the impact on patient outcomes.

Disparities in diabetes prevalence and management by race and ethnicity in the USA: defining a path forward

Type 2 diabetes disparities in the USA persist in both the prevalence of disease and diabetes-related complications. We conducted a literature review related to diabetes prevention, management, and complications across racial and ethnic groups in the USA. The objective of this review is to summarise the current understanding of diabetes disparities by examining differences between and within racial and ethnic groups and among young people (aged <18 years). We also examine the pathophysiology of diabetes as it relates to race and ethnic differences. We use a conceptual framework built on the socioecological model to categorise the causes of diabetes disparities across the lifespan looking at factors in five domains of health behaviours and social norms, public awareness, structural racism, economic development, and access to high-quality care. The range of disparities in diabetes prevalence and management in the USA calls for a community-engaged and multidisciplinary approach that must involve community partners, researchers, practitioners, health system administrators, and policy makers. We offer recommendations for each of these groups to help to promote equity in diabetes prevention and care in the USA.

Utilizing Television Clips for Graduate Medical Education Anti-racist Curricula: An Acceptability Study

Introduction Racism is a pervasive social problem that influences medicine, highlighting the need for interventions. One promising educational technique, referred to as edutainment, utilizes clips from television shows as an instructive strategy. The objective of this study was to examine the acceptability of edutainment around anti-racist curricula for residents. Methods We conducted a survey of underrepresented in medicine (URM) medical faculty to inform content for subsequent focus groups with medicine, psychiatry, and pediatrics residents. For the survey, URM faculty were randomly assigned to view four of eight clips and responded to close- and open-ended items. Focus group participants viewed selected clips and provided feedback. All study procedures occurred in 2020-2021. We calculated descriptive statistics for close-ended survey items and employed thematic analysis for open-ended items and focus group transcripts. Results Twelve URM faculty completed the survey. Feedback was uniformly positive so we included all eight clips in the resident focus groups. For each of the three participating specialties, we conducted two focus groups (2-11 participants each, total n=25) with participants viewing four of the eight clips. Analysis of focus group transcripts found that participants were receptive to the edutainment approach. Feedback as to the realism and acceptability of certain clips differed by specialty. Triangulation of survey and focus group results found differences in the acceptability of specific clips between residents and faculty. Conclusion Edutainment with medical television shows may be a promising avenue for anti-racist curricular content for residents. The educational methods described here are being incorporated into a multi-pronged, hospital system wide graduate medical education anti-racist curriculum.

Implicit Racial Bias Attitudes and Mitigation in Neonatal Nurse Practitioners: A Quality Improvement Project

PURPOSE

to assess the impact of education using the implicit bias recognition and management (IBRM) teaching approach.

DESIGN

longitudinal quasi-experimental design. Surveys at baseline, immediate postimplementation, and 4-week postimplementation using the modified version of the Attitudes Toward Implicit Bias Instrument (ATIBI). The 4-week survey included items about implicit bias recognition and mitigation strategies.

SAMPLE

thirty-six neonatal nurse practitioners assigned to the NICU in a Midwest urban children's hospital.

RESULTS

one-way repeated-measures analysis of variance was used, and the score range was 16-96. The results showed a statistically significant model, F (1.49, 707.97) = 34.46, p <.001, partial η² = 0.496. Pairwise comparisons showed improvement from pre (M = 73.08, SD = 9.36) to immediate postimplementation (M = 80.06, SD = 8.19), p <.001. Scores were sustained at 4-week postimplementation (M = 79.28, SD = 10.39), p = .744.

CONCLUSIONS

The IBRM teaching approach improved scores from baseline on a modified ATIBI that remained improved 4 weeks after the education.

Gender and caste inequalities in primary healthcare usage by under-5 children in rural Nepal: an iterative qualitative study into provider perspectives and the potential role of implicit bias

OBJECTIVE

This study explored provider perspectives on: (1) why inequalities in health service usage persist; and (2) their knowledge and understanding of the role of patient experience and implicit bias (also referred to as unconscious bias).

DESIGN

A three stage, iterative qualitative study was conducted involving two rounds of in-depth interviews and a training session with healthcare staff. Interview transcripts were analysed using a reflexive thematic approach in relation to the study's aims.

SETTING

Participants were recruited from rural hill districts (Mugu, Humla, Bajura, Gorkha and Sindhupalchok) of Nepal.

PARTICIPANTS

Clinical staff from 22 rural health posts.

RESULTS

Healthcare providers had high levels of understanding of the cultural, educational and socioeconomic factors behind inequalities in healthcare usage in their communities. However, there was less knowledge and understanding of the role of patient experience-and no recognition at all of the concept of implicit bias.

CONCLUSION

It is highly likely that implicit bias affects provider behaviours in Nepal, just as it does in other countries. However, there is currently not a culture of thinking about the patient experience and how that might impact on future usage of health services. Implicit bias training for health students and workers would help create greater awareness of unintended discriminatory behaviours. This in turn may play a part in improving patient experience and future healthcare usage, particularly among disadvantaged groups.

Educational strategies in the health professions to mitigate cognitive and implicit bias impact on decision making: a scoping review

BACKGROUND

Cognitive and implicit biases negatively impact clinicians' decision-making capacity and can have devastating consequences for safe, effective, and equitable healthcare provision. Internationally, health care clinicians play a critical role in identifying and overcoming these biases. To be workforce ready, it is important that educators proactively prepare all pre-registration healthcare students for real world practice. However, it is unknown how and to what extent health professional educators incorporate bias training into curricula. To address this gap, this scoping review aims to explore what approaches to teaching cognitive and implicit bias, for entry to practice students, have been studied, and what are the evidence gaps that remain.

METHODS

This scoping review was guided by the Joanna Briggs Institute (JBI) methodology. Databases were searched in May 2022 and included CINAHL, Cochrane, JBI, Medline, ERIC, Embase, and PsycINFO. The Population, Concept and Context framework was used to guide keyword and index terms used for search criteria and data extraction by two independent reviewers. Quantitative and qualitative studies published in English exploring pedagogical approaches and/or educational techniques, strategies, teaching tools to reduce the influence of bias in health clinicians' decision making were sought to be included in this review. Results are presented numerically and thematically in a table accompanied by a narrative summary.

RESULTS

Of the 732 articles identified, 13 met the aim of this study. Most publications originated from the United States (n=9). Educational practice in medicine accounted for most studies (n=8), followed by nursing and midwifery (n=2). A guiding philosophy or conceptual framework for content development was not indicated in most papers. Educational content was mainly provided via face-to-face (lecture/tutorial) delivery (n=10). Reflection was the most common strategy used for assessment of learning (n=6). Cognitive biases were mainly taught in a single session (n=5); implicit biases were taught via a mix of single (n=4) and multiple sessions (n=4).

CONCLUSIONS

A range of pedagogical strategies were employed; most commonly, these were face-to-face, class-based activities such as lectures and tutorials. Assessments of student learning were primarily based on tests and personal reflection. There was limited use of real-world settings to educate students about or build skills in biases and their mitigation. There may be a valuable opportunity in exploring approaches to building these skills in the real-world settings that will be the workplaces of our future healthcare workers.

Implicit bias instruction across disciplines related to the social determinants of health: a scoping review

One criticism of published curricula addressing implicit bias is that few achieve skill development in implicit bias recognition and management (IBRM). To inform the development of skills-based curricula addressing IBRM, we conducted a scoping review of the literature inquiring, "What interventions exist focused on IBRM in professions related to social determinants of health: education, law, social work, and the health professions inclusive of nursing, allied health professions, and medicine?"Authors searched eight databases for articles published from 2000 to 2020. Included studies: (1) described interventions related to implicit bias; and (2) addressed knowledge, attitude and/or skills as outcomes. Excluded were interventions solely focused on reducing/neutralizing implicit bias. Article review for inclusion and data charting occurred independently and in duplicate. Investigators compared characteristics across studies; data charting focused on educational and assessment strategies. Fifty-one full-text articles for data charting and synthesis, with more than 6568 learners, were selected. Educational strategies included provocative/engagement triggers, the Implicit Association Test, reflection and discussion, and various active learning strategies. Most assessments were self-report, with fewer objective measures. Eighteen funded studies utilized federal, foundation, institutional, and private sources. This review adds to the literature by providing tangible examples of curricula to complement existing frameworks, and identifying opportunities for further research in innovative skills-based instruction, learner assessment, and development and validation of outcome metrics. Continued research addressing IBRM would enable learners to develop and practice skills to recognize and manage their implicit biases during clinical encounters, thereby advancing the goal of improved, equitable patient outcomes.

Longitudinal faculty development to improve interprofessional collaboration and practice: a multisite qualitative study at five US academic health centres

OBJECTIVES

Interprofessional (IP) collaboration and effective teamwork remain variable in healthcare organisations. IP bias, assumptions and conflicts limit the capacity of healthcare teams to leverage the expertise of their members to meet growing complexities of patient needs and optimise healthcare outcomes. We aimed to understand how a longitudinal faculty development programme, designed to optimise IP learning, influenced its participants in their IP roles.

DESIGN

In this qualitative study, using a constructivist grounded theory approach, we analysed participants' anonymous narrative responses to open-ended questions about specific knowledge, insights and skills acquired during our IP longitudinal faculty development programme and applications of this learning to teaching and practice.

SETTING

Five university-based academic health centres across the USA.

PARTICIPANTS

IP faculty/clinician leaders from at least three different professions completed small group-based faculty development programmes over 9 months (18 sessions). Site leaders selected participants from applicants forecast as future leaders of IP collaboration and education.

INTERVENTIONS

Completion of a longitudinal IP faculty development programme designed to enhance leadership, teamwork, self-knowledge and communication.

RESULTS

A total of 26 programme participants provided 52 narratives for analysis. Relationships and relational learning were the overarching themes. From the underlying themes, we developed a summary of relational competencies identified at each of three learning levels: (1) Intrapersonal (within oneself): reflective capacity/self-awareness, becoming aware of biases, empathy for self and mindfulness. (2) Interpersonal (interacting with others): listening, understanding others' perspectives, appreciation and respect for colleagues and empathy for others. (3) Systems level (interacting within organisation): resilience, conflict engagement, team dynamics and utilisation of colleagues as resources.

CONCLUSIONS

Our faculty development programme for IP faculty leaders at five US academic health centres achieved relational learning with attitudinal changes that can enhance collaboration with others. We observed meaningful changes in participants with decreased biases, increased self-reflection, empathy and understanding of others' perspectives and enhanced IP teamwork.

Home Health Care Clinicians' Use of Judgment Language for Black and Hispanic Patients: Natural Language Processing Study

BACKGROUND

A clinician's biased behavior toward patients can affect the quality of care. Recent literature reviews report on widespread implicit biases among clinicians. Although emerging studies in hospital settings show racial biases in the language used in clinical documentation within electronic health records, no studies have yet investigated the extent of judgment language in home health care.

OBJECTIVE

We aimed to examine racial differences in judgment language use and the relationship between judgment language use and the amount of time clinicians spent on home visits as a reflection of care quality in home health care.

METHODS

This study is a retrospective observational cohort study. Study data were extracted from a large urban home health care organization in the Northeastern United States. Study data set included patients (N=45,384) who received home health care services between January 1 and December 31, 2019. The study applied a natural language processing algorithm to automatically detect the language of judgment in clinical notes.

RESULTS

The use of judgment language was observed in 38% (n=17,141) of the patients. The highest use of judgment language was found in Hispanic (7,167/66,282, 10.8% of all clinical notes), followed by Black (7,010/65,628, 10.7%), White (10,206/107,626, 9.5%), and Asian (1,756/22,548, 7.8%) patients. Black and Hispanic patients were 14% more likely to have notes with judgment language than White patients. The length of a home health care visit was reduced by 21 minutes when judgment language was used.

CONCLUSIONS

Racial differences were identified in judgment language use. When judgment language is used, clinicians spend less time at patients' homes. Because the language clinicians use in documentation is associated with the time spent providing care, further research is needed to study the impact of using judgment language on quality of home health care. Policy, education, and clinical practice improvements are needed to address the biases behind judgment language.

Provider Characteristics That Hinder Relationships with Black Women in the Perinatal Period

Black women have often reported challenges in their relationships with health care providers during the perinatal period. This study synthesized the findings of qualitative studies to describe health care providers' characteristics that hinder therapeutic relationships with Black women in the perinatal period. A systematic search was conducted and findings from 12 qualitative studies were synthesized using a thematic synthesis approach. Two overarching themes that included seven descriptive themes were discovered. The seven descriptive themes include the following: (1) provides differential treatment; (2) expresses biased attitudes; (3) lacks empathy; (4) limits choices; (5) communicates inadequate health information; (6) provides deficient care; and (7) dismisses concerns. Participants experienced challenged relationships with health care providers who held implicit biases and discouraged them from participating in their care. The findings suggest the importance of confronting implicit biases, promoting a bias-free health care system, and providing quality care that is respectful to Black women in the perinatal period.

Antibias Efforts in United States Maternity Care: A Scoping Review of the Publicly Funded Health Equity Intervention Pipeline

Antibias training is increasingly identified as a strategy to reduce maternal health disparities. Evidence to guide this work is limited. We conducted a community-guided scoping review to characterize new antibias research. Four of 508 projects met our criteria: US-based, publicly funded, initiated from January 1, 2018 to June 30, 2022, and featuring an intervention to reduce bias or racism in maternal health care providers. Training was embedded in multicomponent interventions in 3 projects, limiting its evaluation as a stand-alone intervention. Major public funders have sponsored few projects to advance antibias training research in maternal health. More support is needed to develop a rigorous and scalable evidence base.

An Assessment of the Feasibility and Utility of an ACCC-ASCO Implicit Bias Training Program to Enhance Racial and Ethnic Diversity in Cancer Clinical Trials

PURPOSE

Cancer trial participants do not reflect the racial and ethnic diversity in the population of people with cancer in the United States. As a result of multiple system-, patient-, and provider-level factors, including implicit bias, cancer clinical trials are not consistently offered to all potentially eligible patients.

MATERIALS AND METHODS

ASCO and ACCC evaluated the utility (pre- and post-test knowledge changes) and feasibility (completion rates, curriculum satisfaction metrics, survey questions, and interviews) of a customized online training program combined with facilitated peer-to-peer discussion designed to help research teams identify their own implicit biases and develop strategies to mitigate them. Discussion focused on (1) specific elements of the training modules; (2) how to apply lessons learned; and (3) key considerations for developing a facilitation guide to support peer-to-peer discussions in cancer clinical research settings. We evaluated discussion via a qualitative assessment.

RESULTS

Participant completion rate was high: 49 of 50 participating cancer programs completed training; 126 of 129 participating individuals completed the training (98% response rate); and 119 completed the training and evaluations (92% response rate). Training increased the mean percentage change in knowledge scores by 19%-45% across key concepts (eg, causes of health disparities) and increased the mean percentage change in knowledge scores by 10%-31% about strategies/actions to address implicit bias and diversity concerns in cancer clinical trials. Knowledge increases were sustained at 6 weeks. Qualitative evaluation validated the utility and feasibility of facilitated peer-to-peer discussion.

CONCLUSION

The pilot implementation of the training program demonstrated excellent utility and feasibility. Our evaluation affirms that an online training designed to raise awareness about implicit bias and develop strategies to mitigate biases among cancer research teams is feasible and can be readily implemented in cancer research settings.

The influence of racial-ethnic discrimination on women's health care outcomes: A mixed methods systematic review

BACKGROUND

In the U.S, a wide body of evidence has documented significant racial-ethnic disparities in women's health, and growing attention has focused on discrimination in health care as an underlying cause. Yet, there are knowledge gaps on how experiences of racial-ethnic health care discrimination across the life course influence the health of women of color. Our objective was to summarize existing literature on the impact of racial-ethnic health care discrimination on health care outcomes for women of color to examine multiple health care areas encountered across the life course.

METHODS

We systematically searched three databases and conducted study screening, data extraction, and quality assessment. We included quantitative and qualitative peer-reviewed literature on racial-ethnic health care discrimination towards women of color, focusing on studies that measured patient-perceived discrimination or differential treatment resulting from implicit provider bias. Results were summarized through narrative synthesis.

RESULTS

In total, 84 articles were included spanning different health care domains, such as perinatal and cancer care. Qualitative studies demonstrated the existence of racial-ethnic discrimination across care domains. Most quantitative studies reported a mix of positive and null associations between discrimination and adverse health care outcomes, with variation by the type of health care outcome. For instance, over three-quarters of the studies exploring associations between discrimination/bias and health care-related behaviors or beliefs found significant associations, whereas around two-thirds of the studies on clinical interventions found no significant associations.

CONCLUSIONS

This review shows substantial evidence on the existence of racial-ethnic discrimination in health care and its impact on women of color in the U.S. However, the evidence on how this phenomenon influences health care outcomes varies in strength by the type of outcome investigated. High-quality, targeted research using validated measures that is grounded in theoretical frameworks on racism is needed. This systematic review was registered [PROSPERO ID: CRD42018105448].

Investigating the Relationship between Resident Physician Implicit Bias and Language Use during a Clinical Encounter with Hispanic Patients

Prior research suggests that the implicit biases of physicians are negatively associated with quality of medical care and patient satisfaction among minority patients. However, relatively little is known about how physicians express these subtle forms of bias in patient interactions. This study examined the implicit and explicit anti-Hispanic biases of 53 resident physicians and the relationship between anti-Hispanic bias and language use during outpatient medical appointments with 291 Hispanic patients. Physician implicit bias was positively associated with use of interrogatives and work-related words and negatively associated with the use of prepositions and relativity-related words (e.g., words related to time and the future). These findings contribute to the growing body of evidence suggesting that, in addition to nonverbal and paraverbal behaviors, providers may communicate implicit bias to patients through the words they use during a clinical visit.

Evaluation of a Virtual Health Equity Training for Mid-Career Primary Healthcare Providers

OBJECTIVES

Providing cultural competence training is recommended as a way to improve patient-centered care and reduce health disparities. Increasing awareness of implicit biases and understanding internal motivations for overcoming these biases can influence provider decisions and communications with patients. This study aims to provide a health equity and implicit bias training to healthcare providers and assess knowledge and attitude gains.

METHODS

Mid-career primary healthcare providers (n = 21) with at least 5 years of primary care experience participated in the training as a prerequisite for providing patient care in a telehealth primary care practice that overwhelmingly serves patients of color.

RESULTS

There was a significant increase in knowledge (p < .001) as well as attitudes (p < .001) in healthcare providers from pretest to posttest. Almost none (4.5%) of the providers were distracted during the training, which may be due to the interactive nature of the training that included group-based reflection discussions.

CONCLUSION

A virtual training for primary healthcare providers on health equity and implicit bias improved knowledge and equitable attitudes and had high satisfaction. Additional research is needed to determine if this type of training can influence providers' ability to actively address known disparities in care.

Medical Aid in Dying

As the nation's 75 million baby boomers enter into a new phase of their life, care for their aging parents, and contemplate their own mortality, many have come to realize that our end-of-life care system is hamstrung by outdated modes of dying. This chapter discusses the current status of medical aid in dying in the United States as a legal and medically recognized medical option for supporting patients at life's end.

Anti-racist strategies for clinical and translational research: Design, implementation, and lessons learned from a new course

Translational research should examine racism and bias and improve health equity. We designed and implemented a course for the Master of Science in Clinical Investigation program of the Northwestern University Clinical and Translational Sciences Institute. We describe curriculum development, content, outcomes, and revisions involving 36 students in 2 years of "Anti-Racist Strategies for Clinical and Translational Science." Ninety-six percent of students reported they would recommend the course. Many reported changes in research approaches based on course content. A course designed to teach anti-racist research design is feasible and has a positive short-term impact on learners.

Responsive social support serves important functions in clinical communication: Translating perspectives from relationship science to improve cancer clinical interactions

Patient-clinician interactions are critical to patient-centered care, including in cancer care contexts which are often defined by multiple patient-clinician interactions over an extended period. Research on these dyadic interactions has been guided by perspectives in clinical communication science, but the study of clinical communication has not been fully integrated with perspectives on interpersonal interactions from relationship science research. An overlapping concept in both fields is the concept of responsive socialsupport. In this article, we discuss responsiveness as a concept that offers opportunities for connections between these two disciplines. Next, we focus on how relationship science can be applied to research in clinical settings. We discuss how three areas of relationship science define responsiveness and have potential for extension to clinical communication: (1) (in)visibility of social support, (2) attachment orientations, and (3) shared meaning systems. We also discuss how social biases can impede responsiveness and suggest research avenues to develop ideas and understand potential challenges in connecting these two fields. Many opportunities exist for interdisciplinary theory development that can generate momentum in understanding interpersonal processes in cancer care.

[Structural discrimination and racism in hospital care: the role of the economic conditions in intercultural openness]

BACKGROUND

Racism and structural discrimination in German healthcare have been little studied to date, although intercultural openness has been demanded for many years. At the same time, the processes of economization are progressing, especially in hospital care. This study examines current challenges of intercultural openness, including the influence of the economic framework.

METHODS

One hundred twelve guided interviews were conducted with hospital employees in Berlin from various professional groups and departments. They were asked about challenges, how they were coping, and ideas for solutions.

RESULTS

The consequences of economization are particularly visible in the care of patients with a history of flight or migration. A lack of resources combined with a lack of funding for language mediation leads to overburdening of healthcare workers and the tendency toward culturalization, in which the "culture" of the patients is used to explain their actions, and open racism. The breeding ground for this is the multiple insecurities experienced by staff due to the additional needs of these patients. Culturalization is described as an attempt to cope with their emotional distress in the face of lack of time and staff shortages. First and foremost, the wish for more time and additional staff was voiced. This being granted, further measures to reduce racism and structural discrimination were defined.

DISCUSSION

In order to counteract racism and culturalization, measures that focus on the economic framework conditions and institutional change processes are central.

Implicit Bias Training in Health Professions Education: A Scoping Review

There is a recurrent call for effective implicit bias (IB) education within health professions education (HPE). We aimed to explore the state of IB education within HPE for clinical learners and IB educators using the Arksey and O'Malley scoping review framework. Thirty publications variable in curricular design met inclusion criteria. No studies assessed learner outcomes at the level of Miller's "shows" or "does" nor reported program evaluation outcomes at the level of Kirkpatrick's "behavior" or "results." Rigorous, theory-guided studies assessing behavioral change, patient care delivery, and patient outcomes are needed to move the field of IB education forward within HPE.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-022-01673-z.

Implicit and explicit ethnic biases in multicultural primary care: the case of trainee general practitioners

Background

General Practitioners (GPs) are the first point of contact for people from ethnic and migrant groups who have health problems. Discrimination can occur in this health care sector. Few studies, however, have investigated implicit and explicit biases in general practice against ethnic and migrant groups. This study, therefore, investigated the extent of implicit ethnic biases and willingness to adapt care to migrant patients among trainee GPs, and the factors involved therein, in order to measure explicit bias and explore a dimension of cultural competence.

Methods

In 2021, data were collected from 207 trainee GPs in the French-speaking part of Belgium. The respondents passed an Implicit Association Test (IAT), a validated tool used to measure implicit biases against ethnic groups. An explicit attitude of willingness to adapt care to diversity, one of the dimensions of cultural competence, was measured using the Hudelson scale.

Results

The overwhelming majority of trainee GPs (82.6%, 95% CI: 0.77 – 0.88) had implicit preferences for their ingroup to the detriment of ethnic and migrant groups. Overall, the majority of respondents considered it the responsibility of GPs to adapt their attitudes and practices to migrants’ needs. More than 50% of trainee GPs, however, considered it the responsibility of migrant patients to adapt to the values and habits of the host country.

Conclusions

This study found that the trainee GPs had high to very high levels of implicit ethnic bias and that they were not always willing to adapt care to the values of migrants. We therefore recommend that they are made aware of this bias and we recommend using the IAT and Hudelson scales as educational tools to address ethnic biases in primary care.

From background to solutions: Eliminating sex gaps in clinical electrophysiology practice

Sex, a biological construct, and gender, a sociocultural construct, both influence the epidemiology and outcomes of various cardiac arrhythmias, leading to disparities that have been observed in clinical practice. Addressing disparities is crucial to improve the quality of clinical care. We recognize gender equality as the ultimate goal to ensuring equitable health care and propose the following strategies to achieve the goal: sex- and gender-stratified research, quality improvement initiatives, implicit bias training, promotion of women into leadership positions in cardiology, peer support, and shared decision-making to help mitigate disparities. However, further research on how to improve the widespread adoption and implementation of such strategies in the clinical setting is required.

Pain-related stigma as a social determinant of health in diverse pediatric pain populations

Pediatric patients with invisible symptomology, such as chronic pain syndromes, are more likely to experience pain-related stigma and associated discrimination by others, including medical providers, peers, school personnel, and family members. The degree of this pain-related stigma may depend on several social dimensions, including observer (e.g., attentional and implicit biases) and patient characteristics (e.g., racial identity, socioeconomic stressors). In this mini-review, we introduce the concept of pain-related stigma, and the intersectionality of stigma, within the context of social determinants of health in pediatric pain populations. Stigma theory, observer attentional biases, healthcare provider implicit/explicit biases, adverse childhood experience, and psychophysiology of socio-environmental stressors are integrated. Several ethical, clinical, and research implications are also discussed. Because the study of pain-related stigma in pediatric pain is in its infancy, the purpose of this conceptual review is to raise awareness of the nuances surrounding this social construct, propose avenues through which stigma may contribute to health inequities, present frameworks to advance the study of this topic, and identify areas for further investigation.

School Mental Health Professionals' Knowledge of Stereotypes and Implicit Bias Toward Black and Latinx Youths

Clinician bias is a contributor to health care inequities, but research on racial-ethnic bias among mental health professionals, especially toward minoritized youths, is limited. This column describes two studies involving mental health clinicians in schools, where most youths access mental health services. Study 1 used a mixed-methods approach to identify stereotypes about Black and Latinx youths salient to clinicians (e.g., academic failure; anger and aggression). In study 2, the authors developed four Implicit Association Tests to assess clinicians' implicit prejudice and stereotyping of Black and Latinx youths and found pro-White and anti-Black/Latinx bias at levels similar to those of other health care providers and the general population.

Consensus on an implicit bias and health disparities curriculum in neonatal medicine: a Delphi study

OBJECTIVE

Despite longstanding and recurrent calls for effective implicit bias (IB) education in health professions education as one mechanism to reduce ongoing racism and health disparities, such curricula for neonatal-perinatal medicine (NPM) are limited. We aim to determine the key curricular elements for educating NPM fellows, advanced practice providers, and attending physicians in the critical topics of IB and health disparities.

STUDY DESIGN

A modified Delphi study was performed with content experts in IB and health disparities who had educational relationships to those working and training in the neonatal intensive care unit.

RESULT

Three Delphi rounds were conducted from May to November 2021. Experts reached consensus on a variety of items for inclusion in the curriculum, including educational goals, learning objectives, teaching strategies, and educator principles.

CONCLUSION

Essential curricular components of an IB and health disparities curriculum for neonatal medicine were defined using rigorous consensus building methodology.

Socioeconomic status and outcomes after in-hospital cardiac arrest

AIM

To investigate the association between socioeconomic status and outcomes after in-hospital cardiac arrest in Denmark.

METHODS

We conducted an observational cohort study based on nationwide registries and prospectively collected data on in-hospital cardiac arrest from 2017 and 2018 in Denmark. Unadjusted and adjusted analyses using regression models were performed to assess the association between socioeconomic status and outcomes after in-hospital cardiac arrest. Outcomes included return of spontaneous circulation (ROSC), survival to 30 days, survival to one year, and the duration of resuscitation among patients without ROSC.

RESULTS

A total of 3,223 patients with in-hospital cardiac arrest were included in the study. In the adjusted analyses, high household assets were associated with 1.20 (95 %CI: 0.96, 1.51) times the odds of ROSC, 1.49 (95 %CI: 1.14, 1.96) times the odds of survival to 30 days, 1.40 (95 %CI: 1.04, 1.90) times the odds of survival to one year, and 2.8 (95 %CI: 0.9, 4.7) minutes longer duration of resuscitation among patients without ROSC compared to low household assets. Similar albeit attenuated associations were observed for education. While high household income was associated with better outcomes in the unadjusted analyses, these associations largely disappeared in the adjusted analyses.

CONCLUSIONS

In this study of patients with in-hospital cardiac arrest, we found that high household assets were associated with a higher odds of survival and a longer duration of resuscitation among patients without ROSC compared to low household assets. However, the effect size may potentially be small. The results varied based on socioeconomic status measure, outcome of interest, and across adjusted analyses.

Patient perspectives of the climate of diversity, equity, and inclusion in the emergency department

Objective

Assessing the diversity, equity, and inclusion (DEI) climate of emergency departments (EDs) can inform organizational change to provide equitable, inclusive, and high-quality care to their diverse patient populations. The purpose of this project was to investigate patient perspectives on the climate of DEI in an urban ED.

Methods

This was a cross-sectional survey study conducted in a large-volume, urban ED in Detroit, MI, from November 2018 to January 2019. The survey was developed by an experienced ED DEI committee via an iterative process and broad consensus.

Results

During their care in the ED, 849 patients completed an anonymous survey about their perspectives and experiences of DEI in that ED. Overall, the responses were favorable as most respondents reported that the ED staff treated patients from all races equally (75.8%) and made patients feel accepted (86%). However, some respondents felt that the ED staff's treatment of populations with greater complexity, such as patients who are mentally ill (16.8%) or lower income (14.3%), needs the most improvement.

Conclusions

This DEI climate assessment survey of ED patients' perspectives revealed important insights that could guide strategic initiatives to advance DEI in the ED. This assessment may serve as a model for continuous evaluation of DEI over time and in multiple healthcare settings to help guide organizational change efforts.

Confronting implicit bias toward patients: a scoping review of post-graduate physician curricula

BACKGROUND

Physicians' behavior may unknowingly be impacted by prejudice and thereby contribute to healthcare inequities. Despite increasingly robust data demonstrating physician implicit bias (The Office of Minority Health. Minority Population Profiles, 2021; COVID-19 Shines Light on Health Disparities, National Conference of State Legislatures 2021), the evidence behind how to change this with training programs remains unclear. This scoping review therefore reports on the implementation, outcomes, and characteristics of post-graduate physician implicit bias curricula.

METHODS

The authors conducted a literature review using scoping review methodology. They searched 7 databases in February and November 2020 for English-language academic and gray literature on implicit bias curricula for physicians at all levels of post-graduate training. Ten reviewers screened studies for eligibility independently, then extracted data from these studies and compiled it into a chart and analytical summary.

RESULTS

Of the 4,599 articles screened, this review identified 90 articles on implicit bias interventions for post-graduate physicians. Inductive data analysis revealed a spectrum of educational approaches, which were categorized int o 4 educational models called Competence, Skills-Based, Social Contact, and Critical Models. The most commonly reported strength was the interactive nature of the curricula (26%), and the most frequently identified challenges were related to time and resources available (53%). Half of the interventions discussed facilitator preparation, and the majority (62%) evaluated outcomes using pre and post self-assessments.

CONCLUSIONS

This review provides a comprehensive synthesis of the literature on physician implicit bias curricula. It is our goal that this supports medical educators in applying and improving aspects of these interventions in their own programs.

A Conceptual Model to Guide Patient-to-Provider Communication of Adverse Childhood Experiences in Primary Care

Communicating with adults about childhood adversity is not an innate clinical skill nor is it a routine assessment element. Nurse practitioners may be aware of the significance adverse childhood experience (ACE) exposure has on adult health and well-being; however, they may not be prepared to identify, interpret, and subsequently act on that information. This article presents the development of a conceptual model to guide patient-to-provider communication of adverse childhood experiences in primary care (the PPC-ACE model). This includes a description of the model and its associated foundational elements, underlying assumptions, implications for nursing practice, and opportunities to use this model to guide future ACEs-related research.