Self-Awareness and Cultural Identity as an Effort to Reduce Bias in Medicine

Racial Implicit Bias and Communication Among Physicians in a Simulated Environment

Importance

Racial implicit bias can contribute to health disparities through its negative influence on physician communication with Black patients. Interventions for physicians to address racial implicit bias in their clinical encounters are limited by a lack of high-fidelity (realistic) simulations to provide opportunities for skill development and practice.

Objective

To describe the development and initial evaluation of a high-fidelity simulation of conditions under which physicians might be influenced by implicit racial bias.

Design, Setting, and Participants

This cross-sectional study, performed on an online platform from March 1 to September 30, 2022, recruited a convenience sample of physician volunteers to pilot an educational simulation.

Exposures

In the simulation exercise, physicians saw a 52-year-old male standardized patient (SP) (presenting as Black or White) seeking urgent care for epigastric pain, nausea, and vomiting. The case included cognitive stressors common to clinical environments, including clinical ambiguity, stress, time constraints, and interruptions. Physicians explained their diagnosis and treatment plan to the SP, wrote an assessment and management plan, completed surveys, and took the Race Implicit Association Test (IAT) and Race Medical Cooperativeness IAT. The SPs, blinded to the purpose of the study, assessed each physician's communication using skills checklists and global rating scales.

Main Outcomes and Measures

Association between physicians' IAT scores and SP race with SP ratings of communication skills.

Results

In 60 physicians (23 [38.3%] Asian, 4 [6.7%] Black, 23 [38.3%] White, and 10 [16.7%] other, including Latina/o/x, Middle Eastern, and multiracial; 31 [51.7%] female, 27 [45.0%] male, and 2 [3.3%] other), the interaction of physicians' Race IAT score and SP race was significant for overall communication (mean [SD] β = -1.29 [0.41]), all subdomains of communication (mean [SD] β = -1.17 [0.52] to -1.43 [0.59]), and overall global ratings (mean [SD] β = -1.09 [0.39]). Black SPs rated physicians lower on communication skills for a given pro-White Race IAT score than White SPs; White SP ratings increased as physicians' pro-White bias increased.

Conclusions and Relevance

In this cross-sectional study, a high-fidelity simulation calibrated with cognitive stressors common to clinical environments elicited the expected influence of racial implicit bias on physicians' communication skills. The outlined process and preliminary results can inform the development and evaluation of interventions that seek to address racial implicit bias in clinical encounters and improve physician communication with Black patients.

Health Equity and Policy Considerations for Pediatric and Adult Congenital Heart Disease Care among Minoritized Populations in the United States

Achieving health equity in populations with congenital heart disease (CHD) requires recognizing existing disparities throughout the lifespan that negatively and disproportionately impact specific groups of individuals. These disparities occur at individual, institutional, or system levels and often result in increased morbidity and mortality for marginalized or racially minoritized populations (population subgroups (e.g., ethnic, racial, social, religious) with differential power compared to those deemed to hold the majority power in the population). Creating actionable strategies and solutions to address these health disparities in patients with CHD requires critically examining multilevel factors and health policies that continue to drive health inequities, including varying social determinants of health (SDOH), systemic inequities, and structural racism. In this comprehensive review article, we focus on health equity solutions and health policy considerations for minoritized and marginalized populations with CHD throughout their lifespan in the United States. We review unique challenges that these populations may face and strategies for mitigating disparities in lifelong CHD care. We assess ways to deliver culturally competent CHD care and to help lower-health-literacy populations navigate CHD care. Finally, we review system-level health policies that impact reimbursement and research funding, as well as institutional policies that impact leadership diversity and representation in the workforce.

Challenges and Opportunities for Implementing Diversity Competence in a Medical Education Curriculum: A Qualitative Study of Perceptions Among Students and Teachers

OBJECTIVES

Medical education is under continuous pressure to introduce new curriculum content to ensure that physicians possess the competences that the population needs. Diversity competence (DC) is a relatively new area within medicine, challenging the existing curriculum. Frameworks and guidelines have been developed to provide support and assistance to educators in integrating DC into medical programs. However, integrating DC into curriculum has proven difficult and is therefore still not included in many European medical programs. The purpose of the study is therefore to identify the challenges and opportunities for implementing DC including a focus on migrant and ethnic minorities in a medical education program.

METHODS

From November 2-20, 2020, focus group discussions with medical students, junior physicians and course leaders were conducted. The participants were recruited via Facebook, newsletters, and emails. Two interview guides were developed and used as guidance for topics to be discussed. The focus group discussions were conducted partly physically and partly digitally. The interviews were transcribed and were analyzed using thematic analysis.

RESULTS

Three main challenges and opportunities were identified across the focus groups. Challenges: (i) a disparaging discourse about humanistic and social disciplines within the curriculum, (ii) limited levels of DC among teachers, and (iii) need for institutional support. Opportunities: (i) a clear interest in strengthening teachers' DC levels, (ii) incentives for improving the image of humanistic and social medicine, and (iii) relevant courses for implementing DC.

CONCLUSION

Our results showed that action in this area is needed. The themes identified indicated that there are within the curriculum many opportunities to implement DC, but they also illuminated the challenges. The results suggested both a need for focusing on individual competences for medical teachers and students, and also for organizational change and support in favor of DC training.

Diversity competence training for health professionals in Europe: a modified delphi study investigating relevant content for short or online courses

BACKGROUND

Diversity is a reality in our societies, requiring health professionals to adapt to the unique needs of all patients, including migrants and ethnic minorities. In order to enable health professionals to meet related challenges and reduce health disparities, long and demanding training courses have been developed. But due to busy schedules of professionals and often scarce resources, a need for shorter training courses exists. This study aims to investigate which topics and methods should be prioritised in designing basic diversity training courses that provide health professionals the opportunity to foster this competence.

METHODS

The study provided an expert panel of 31 academic and clinical migrant health experts with the content and methods of an existing diversity training course. The panel was asked to prioritise training topics and teaching methods in a two-stage process, using an adapted Delphi method. In the first stage, experts rated 96 predefined items, commented on those items, provided answers to eight open-ended questions and suggested additional content for a short course. In the second stage, they commented on the ratings from Round 1, and rated new suggested content. Consensus for training topics was set to 80% and for teaching methods 70%.

RESULTS

The entire panel deemed 'health effects of migration (pre-, during- and post-migration risk factors)' to be important or very important to include in a short/online, basic diversity training (100% consensus). Other high-scoring items and therefore topics to be included in trainings were 'social determinants of health' (97%) and 'discrimination within the healthcare sector' (also 97%). A general trend was to focus on reflective practice since almost all items regarding reflection reached consensus. 'Reflection on own stereotypes and prejudices' (97%) was the highest-rated reflection item. 'Opportunities and best practices in working with interpreters' was the highest-scoring skills item, both on consensus (96%) and mean value (5.77).

CONCLUSIONS

Experts' prioritizations of teaching content and methods for diversity training can help the design of short (online) trainings for health professionals and reduce unnecessary course content, thereby fostering professional development and enabling diversity competence trainings to be implemented also when time and/or financial resources are limited.

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.

AI in Pathology: What could possibly go wrong?

The field of medicine is undergoing rapid digital transformation. Pathologists are now striving to digitize their data, workflows, and interpretations, assisted by the enabling development of whole-slide imaging. Going digital means that the analog process of human diagnosis can be augmented or even replaced by rapidly evolving AI approaches, which are just now entering into clinical practice. But with such progress comes challenges that reflect a variety of stressors, including the impact of unrepresentative training data with accompanying implicit bias, data privacy concerns, and fragility of algorithm performance. Beyond such core digital aspects, considerations arise related to difficulties presented by changing disease presentations, diagnostic approaches, and therapeutic options. While some tools such as data federation can help with broadening data diversity while preserving expertise and local control, they may not be the full answer to some of these issues. The impact of AI in pathology on the field's human practitioners is still very much unknown: installation of unconscious bias and deference to AI guidance need to be understood and addressed. If AI is widely adopted, it may remove many inefficiencies in daily practice and compensate for staff shortages. It may also cause practitioner deskilling, dethrilling, and burnout. We discuss the technological, clinical, legal, and sociological factors that will influence the adoption of AI in pathology, and its eventual impact for good or ill.

The Social Contexts of Birthing People with Public- and Private-Payer Prenatal Care: Illuminating an Understudied Aspect of the Patient Experience

Purpose

In pursuit of more equitable and person-centered health care, patients and professional medical societies increasingly call for better clinician understanding of patients' perspectives and social contexts. A foundational but understudied aspect of patients' social contexts are the ideas they encounter about health-related behaviors. We investigated this aspect of the social contexts of birthing people, comparing those with public versus private insurance to discover setting-specific insights.

Methods

Based on ethnographic fieldwork, we created an original survey featuring 29 statements about 12 prenatal, perinatal, and postpartum health behaviors (e.g., drinking alcohol, epidural use, breastfeeding). Participants were 248 individuals receiving prenatal care in Northern California in 2009-2011, split evenly between public- and private-payer coverage. Participants reported whether they were familiar or unfamiliar with each statement.

Results

Ninety-eight percent of all participants had heard contradictory ideas about ≥1 health behavior (mean=3.9 behaviors for public- and 5.4 for private-coverage respondents). For 20 of the 29 behavior-related ideas, exposure varied significantly by coverage type. Among other differences, public-coverage respondents were much more familiar with ideas related to risk and constrained autonomy (e.g., that serious perinatal complications are common; that new mothers should try to breastfeed even if they do not want to).

Conclusions

Birthing people are exposed to a wide range of ideas about health behaviors, many of which vary by the structural systems in which they are embedded. Understanding and engaging this complexity can help clinicians to provide more respectful, person-centered, and equitable maternity care.

Veterinary and Pharmacy Students' Expectations Before and Experiences After Participating in an Interdisciplinary Access to Care Veterinary Clinic, WisCARES

This pilot survey study describes student expectations and experiences at WisCARES, a low-cost veterinary medical teaching clinic where students from multiple disciplines collaborate. We hypothesized that prior to the workday, students would describe different expectations of working in an interdisciplinary access to care clinic than what they ultimately experienced. We surveyed 62 students from the School of Veterinary Medicine (46) and pharmacy (16) who spent a clinic day at WisCARES. Before introductory rounds, students completed a short survey consisting of four open-ended questions about their learning expectations; at the end of the day, they reviewed their initial responses and added what they actually learned. Qualitative information was categorized and analyzed using descriptive statistics. Thirteen major themes emerged: diversity, confidence, communication, case lead/case management, financial experience, helping people, teamwork, technical skills, inter-professional experience, mentoring, non-specific positive regard, appreciation for resources, and rounds. Students reported improved confidence in managing and leading cases with specific positive outcomes in communicating with clients, particularly regarding leading financial conversations. Developing greater insight into diversity was a common theme expressed in students' expectations but was less frequently noted as an end-of-day outcome. Veterinary students less frequently described the value of the inter-professional environment and collaboration, but this was a major theme noted among pharmacy students. Student feedback was positive overall. The current study is useful in identifying areas for improving collaborative instruction and access to care professional student learning opportunities.

The Impact of Nurses' Beliefs, Attitudes, and Cultural Sensitivity on the Management of Patient Pain

INTRODUCTION

Nurses' attitudes and beliefs may impact pain management. This study investigated nurses' perceptions regarding their own and patients' pain experiences by examining relationships between pain cautiousness and stoicism, cultural sensitivity, and personal pain attitudes.

METHODOLOGY

A correlational methodology examined nursing staff in a Midwestern private hospital. The sample included 102 primarily female (95.1%), Caucasian (97%), and married (66%) nursing staff. Measures included the Intercultural Sensitivity Scale, Pain Attitudes Questionnaire to Assess Stoicism and Cautiousness, and the Pain Management: Nurses' Knowledge and Attitude Survey.

RESULTS

Cultural sensitivity was a significant predictor of pain knowledge and attitudes total score (R² = .081, β = .244, p = .040), while pain stoicism and pain cautiousness were not predictive.

DISCUSSION

Findings highlight the importance of nurses being aware of personal attitudes, beliefs, and cultural sensitivity in pain management. Results also demonstrate a gap between the knowledge and utilization of nonpharmacologic pain management interventions among nursing staff.

Addressing the Challenges of Cross-Cultural Communication

Cross-cultural communication has many challenges due to the complexity of culture, communication, and language. Improving cross-cultural communication in health care is critical to reducing disparities and improving health equity. Specifically, improving cross-cultural communication must be prioritized to overcome systemic barriers and to eliminate disparities that stem from stigma and biases. Communication must be improved, ideally via a cultural humility framework. Unconscious bias and communication training must be intentional. Culture is an attribute and should be celebrated and incorporated into health practice at all levels to prioritize health equity.

Proyecto ELEVAR: Evaluating the Latinx Experience With the Health Care System Through Variables on Access and Resources

PURPOSE

Hispanic/Latinx communities encounter disparities in access and availability of appropriate timely health care services, negatively affecting cancer outcomes. Limited data exist on the role of these factors in personal experiences of Hispanic/Latinx with health care systems. We aim to better understand Hispanic/Latinx experience with the health care system, focusing on the impact of the Affordable Care Act (ACA) and applications to clinical practice in patients diagnosed with cancer.

METHODS

Competitively obtained data from 2010 to 2019 Association of American Medical Colleges Consumer Survey of Health Care Access (a US population-based sample of potential health care consumers needing health care at least once in the past year) were retrospectively reviewed. Descriptive statistics and univariate and multivariate comparisons of patterns pre- versus post-ACA were performed for respondents self-identifying as Hispanic/Latinx.

RESULTS

In a total cohort of 53,523 respondents, Hispanic/Latinx comprised 7.5% (n = 4,094). Post-ACA demographics showed a higher proportion of female and an increase in employment, educational attainment, income, and private insurance coverage, with a decrease in uninsured. Adjusted models showed that post-ACA Hispanic/Latinx patients are less likely to use emergency room if sick or needing medical advice (odds ratio [OR] 0.33; P < .001) and more likely to report chronic conditions involving cancer (OR 2.43; P < .001) or being limited in activities because of mental or emotional problems (OR 1.36; P = .005).

CONCLUSION

Although ACA implementation was associated with decreased health care access barriers in Hispanic/Latinx, they continue to experience disparities in chronic health conditions, including cancer, with higher limitations because of emotional or mental health. Ongoing efforts that build upon current strides, toward improved patient satisfaction and overall outcomes, are of paramount importance.

Connections and Biases in Health Equity and Culture Research: A Semantic Network Analysis

Health equity is a rather complex issue. Social context and economical disparities, are known to be determining factors. Cultural and educational constrains however, are also important contributors to the establishment and development of health inequities. As an important starting point for a comprehensive discussion, a detailed analysis of the literature corpus is thus desirable: we need to recognize what has been done, under what circumstances, even what possible sources of bias exist in our current discussion on this relevant issue. By finding these trends and biases we will be better equipped to modulate them and find avenues that may lead us to a more integrated view of health inequity, potentially enhancing our capabilities to intervene to ameliorate it. In this study, we characterized at a large scale, the social and cultural determinants most frequently reported in current global research of health inequity and the interrelationships among them in different populations under diverse contexts. We used a data/literature mining approach to the current literature followed by a semantic network analysis of the interrelationships discovered. The analyzed structured corpus consisted in circa 950 articles categorized by means of the Medical Subheadings (MeSH) content-descriptor from 2014 to 2021. Further analyses involved systematic searches in the LILACS and DOAJ databases, as additional sources. The use of data analytics techniques allowed us to find a number of non-trivial connections, pointed out to existing biases and under-represented issues and let us discuss what are the most relevant concepts that are (and are not) being discussed in the context of Health Equity and Culture.

Mind the Gate: General Practitioner's Attitudes Towards Depressed Patients with Diverse Migration Backgrounds

This study aims to examine (a) whether there are differences in general practitioners' (GPs) attitudes towards native Belgian patients, patients of foreign descent and asylum seeking patients who all express symptoms of major depression, and (b) whether these differences depend on GPs' experience with cultural competency training and interethnic contact. Using a video vignette study among 404 Flemish (Belgium) GPs, we find evidence of a provider bias. While GPs regard a patient of foreign descent as less trustworthy and less able to adhere to medical recommendations than a native Belgian patient, they also hold more pessimistic views on a potential recovery of an asylum seeking patient. In addition, we find that cultural competency training might alter GPs' attitudes of asylum seeking patients in a positive way. Summarized, our research highlights the need to target stereotypes among GPs for interventions designed to reduce migration-based disparities in healthcare use and health status.

Urban Image at the Time of the COVID-19 Pandemic, Case Study Novi Sad (Serbia)

The main aim of this paper is to examine how negative phenomena, such as a pandemic, can result in positive cultural shifts and an upgrade of the urban image. The research was conducted employing an in-depth interview approach at the end of 2021, based on a semi-structured protocol with 15 participants. The answers of the respondents are conditioned by the socio-demographic differences. They show the urban image and cultural opportunities of the city. The image of the city is changing under different cultural influences, which are caused by events in the region or globalization. The self-awareness of the history, tradition and heritage that the people of Novi Sad have should be nurtured in order to preserve the image of the city with the strength of the majority of the immigrant population. The title ‘European Capital of Culture’ has been well received, but its impact will be best seen at the end of the year. COVID-19The COVID-19 pandemic favored and popularized cycling, awakened environmental self-awareness and solidarity, brought culture to the streets and beautified the city’s image. Everything that could not be placed on the street, it was entered and placed in the virtual world.

Cultural responsiveness in applied behavior analysis: Self-assessment

Culture has a substantial impact on a wide range of behaviors related to behavioral research and services such as rapport building, preferences for specific targets and treatments, communication, and even the quality of health care. The need for professionals in the field of applied behavior analysis (ABA) to incorporate culturally responsive practices is underscored by the current and projected increase in diversity in the United States. Further, the update to the Ethics Code (BACB, 2020) supports addressing diversity in behavior analytic practice. Self-assessment of one's values, biases, and culture are a critical step in delivering culturally responsive services. The purpose of this paper is three-fold: a) to introduce a framework for cultural responsiveness in ABA, b) to showcase research and practice recommendations from within and outside the field of ABA in the area of self-assessment, and c) to inspire research in self-assessment to support cultural responsiveness in ABA.

Development of a 1-Week Intensive Course on Diversity and Equity in Veterinary Medicine

While colleges of veterinary medicine continually strive to promote diversity and inclusion on their campuses, few offer dedicated diversity courses within their curriculums. This article provides details on the development and implementation of a 1-week intensive course on equity and diversity in veterinary medicine, discusses the strengths and challenges encountered, and provides suggestions for those seeking to develop similar learning experiences into their curriculum. This selective course was developed to introduce students to the principles of social justice and provide them with the opportunity to examine systems of power, privilege, and oppression within the context of veterinary medicine.

An example of functional integration and application of diversity, inequities, and social determinants of health in an applied physiology course

Increasing diversity, including diverse perspectives in science, technology, engineering, and math (STEM) classrooms and teaching practices, is recognized as a current higher education priority. Resources to assist institutions and instructors are growing; however, many STEM instructors still hesitate to implement diverse teaching practices and discussions of diversity issues in their courses for a variety of reasons. This paper describes an example of the incorporation and discussion of diversity and social justice issues as part of an upper level physiology of aging course. The general approach was to examine the functional intersection of the sociology and physiology using social determinants of health as mechanistic influencers of physiology and examining how they affect healthy aging and etiology of age-associated diseases. Activities included in-class and virtual discussion, collaboration with the university diversity department, and a written assignment where the students explored in depth how a social determinant of health affected molecular physiology of aging. Students were also provided with strategies they can use in careers as health practitioners to be more inclusive in their practices. Student participation and feedback indicated that this approach and activities were engaging, enlightening and useful and should be continued. They specifically appreciated the social issues discussed in their sociology courses being included in their physiology major course and thinking about how those issues are mechanistically linked to physiology. This was the first attempt at this approach, and strategies for future activity improvement and tips for successful implementation are also addressed.

We are part of the problem: the role of children's hospitals in addressing health inequity

Racism is an ongoing public health crisis that undermines health equity for all children in hospitals across our nation. The presence and impact of institutionalized racism contributes to health inequity and is under described in the medical literature. In this review, we focus on key interdependent areas to foster inclusion, diversity, and equity in Children's Hospitals, including 1) promotion of workforce diversity 2) provision of anti-racist, equitable hospital patient care, and 3) prioritization of academic scholarship focused on health equity research, quality improvement, medical education, and advocacy. We discuss the implications for clinical and academic practice.Plain Language Summary: Racism in Children's Hospitals harms children. We as health-care providers and hospital systems are part of the problem. We reviewed the literature for the best ways to foster inclusion, diversity, and equity in hospitals. Hospitals can be leaders in improving child health equity by supporting a more diverse workforce, providing anti-racist patient care, and prioritizing health equity scholarship.

Integrating Cultural Humility into the Medical Education Curriculum: Strategies for Educators

ISSUE

The framework of cultural humility, which emphasizes curiosity and self-reflection over mastery, was identified over 20 years ago as a way to address implicit bias in health care, an important factor in health disparities. Despite growing interest from researchers and educators, as well as the urgent call to adopt these values, the foundational elements of cultural humility remain challenging to teach in medical education and have not yet been widely adopted.

EVIDENCE

Health disparities persist throughout the United States among a growing population of diverse patients. The cultural humility framework undermines power imbalances by encouraging the clinician to view their patient as an expert of their own experience. This approach strengthens relationships within the community, illuminates racial and historical injustices, and contributes to equitable care. However, recent reviews have shown that humility-based principles have yet to be widely integrated into cultural curricula. Based on available evidence, this article introduces the foundational concepts of cultural humility with the aim of helping medical educators better understand and implement the principles of cultural humility into undergraduate medical education.

IMPLICATIONS

Cultural humility is a powerful and feasible adjunct to help student physicians cultivate effective tools to provide the best patient care possible to an increasingly diverse patient population. However, there is little known about how best to implement the principles of cultural humility into existing undergraduate medical education curricula. The analyses and strategies presented provide educators with the background, instructional and curricular methods to enable learners to cultivate cultural humility. Future systematic research will need to focus on investigating design, implementation and impact.

Addressing Positionality Within Case-Based Learning to Mitigate Systemic Racism in Health Care

BACKGROUND

Case-based learning has historically focused on the individual patient; however, there is often little consideration within this teaching method of how social determinants of health, such as structural racism and its adverse health effects, bear upon patients' health status and consequent patient outcomes.

PROBLEM

Implementing case studies necessitates taking into account the positionality of patients, as well as health care providers, to counter the racial oppression and discrimination embedded in existing health care and educational systems.

APPROACH

We describe a process for creating an inclusive, antiracist environment for case-based learning within nursing education, outlining steps for preparing students to more effectively examine case studies through social determinants of health framing and lens to mitigate harmful impacts from systemic racism and racial discrimination in clinical care.

CONCLUSIONS

Addressing positionality in case-based learning is one antiracist strategy to begin rectifying health disparities and moving health care toward equity.

Alternatives to Student Outbound Mobility-Improving Students' Cultural Competency Skills Online to Improve Global Health Without Travel

Introduction

Student outbound mobility is a major element in internationalization of medical education and global health education. However, this approach is often criticized, as it is inherently inequitable. Internationalization at home is a newer concept that aims to provide students with international skills and experiences without exchange travel. We report detailed outcomes of an international online program during the COVID-19 pandemic, which aimed to include acquisition of cultural awareness and competency-similar to what the students would have obtained if they had travelled abroad.

Method

Sixty-eight students from 12 international universities participated in international small peer group collaborative work, and online networking. Perceived improvement of cultural competency using Likert scale and open-ended questions was used as a measure of success. Furthermore, students' definition of cultural competency in the different countries was obtained.

Results

Students improved their cultural competency skills. Data analysis supported statistically significant improvement of the above skills after the program, in comparison to the start of the program.

Discussion

Internationalization of medical education can be achieved at home-via structured online peer exchanges-and can provide students with intercultural skills and networking opportunities that are typically achieved via international in-person travel. The above represents a socially just and equitable way to reach all students and can result in improvement of their cultural competency, preparing them for their work in global health, and thereby resulting in improvement of global health.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-021-01332-9.

Implicit Bias Recognition and Management: Tailored Instruction for Faculty

BACKGROUND

Implicit bias instruction is becoming more prevalent across the continuum of medical education. Little guidance exists for faculty on recognizing and debriefing about implicit bias during routine clinical encounters.

OBJECTIVE

To assess the impact and feasibility of single seminars on implicit bias and the approach to its management in clinical settings.

METHODS

Between September 2016 and November 2017, the authors delivered five departmental/divisional grand rounds across three different academic medical centers in New York, USA. Instruction provided background information on implicit bias, highlighted its relevance to clinical care, and discussed proposed interventions. To evaluate the impact of instruction participants completed a twelve-item retrospective pre-intervention/post-intervention survey. Questions related to comfort and confidence in recognizing and managing implicit bias, debriefing with learners, and role-modeling behaviors. Participants identified strategies for recognizing and managing potentially biased events through free text prompts. Authors qualitatively analyzed participants' identified strategies.

RESULTS

We received 116 completed surveys from 203 participants (57% response rate). Participants self-reported confidence and comfort increased for all questions. Qualitative analysis resulted in three themes: looking inward, looking outward, and taking action at individual and institutional levels.

CONCLUSION

After a single session, respondents reported increased confidence and comfort with the topic. They identified strategies relevant to their professional contexts which can inform future skills-based interventions. For healthcare organizations responding to calls for implicit bias training, this approach has great promise. It is feasible and can reach a wide audience through usual grand rounds programming, serving as an effective early step in such training.

Assessing Asian Medical Students' Readiness for Diversity: Localizing Measures of Cross-Cultural Care Competence

Phenomenon: There is now broad acceptance that the development of cross-cultural competence (CCC) supports the delivery of appropriate care to diverse groups and is an essential component in medical education worldwide. CCC training in East Asian contexts has been constrained by the fact that "cultural diversity" training globally has focused primarily on the needs of racial and ethnic communities, to the relative neglect of other groups. The present study explores Taiwanese students' perceptions of CCC provision to identify gaps in local medical education and thus facilitate a more systematic delivery of CCC. Approach: Using an adapted and translated version of the Cross-Cultural Care Survey developed by Harvard Medical School, we collected 1567 student responses from four geographically-distributed Taiwanese medical schools between 2015 and 2017. In addition to student responses, we also collected 122 clinical teacher responses from two of the four medical schools that were surveyed to cross-examine the students' self-perceived competence. The data were analyzed with SPSS and ANOVA was employed with student data to compare the differences among different stages. The analysis focuses on CCC in 4 stages of training: general education, basic pre-clinical and integrated clinical sciences, clerkship, and internship. Findings: The findings show that students felt unprepared to deal with health disparities and the needs of diverse groups and there was no evidence of an increased sense of preparedness in the development of relevant skills in the analyses of the pre-clinical to clinical stages of the curriculum. Similarly, teachers also perceived students across the different stages of training to be unprepared in dealing with the health disparities and needs of diverse groups. However, although findings from teachers' responses parallel those from students, teachers tend to perceive students to be even more unprepared than they perceive themselves to be. The training for CCC appeared inadequate from both set of data and students perceive CCC training to be less explicitly evident in the medical program as it advances from the foundation stage to the pre-clinical stage. Insights: The study raises some crucial issues in terms of diversity and CCC training in medical education programs. The fact that increased awareness of health disparities and the needs of diverse groups fails to be aligned with a sense of preparedness and skillfulness confirms that CCC has not been explicitly and sufficiently addressed in the medical curriculum, particularly in the pre-clinical stage when the focus is on acquiring scientific and technical knowledge. This study shows how a questionnaire designed by and for an American medical institution situated in a highly diverse society can be adapted so that its findings serve as a baseline for medical education programs in Taiwan, and perhaps in other countries that are beginning to acknowledge hitherto "hidden" diversity. This study also has implications which indicate that CCC is crucial in the delivery of appropriate care by members of the medical profession to diverse patients.

Qualitative analysis of medical student reflections on the implicit association test

INTRODUCTION

Health professions educators use the Implicit Association Test (IAT) to raise awareness of implicit bias in learners, often engendering strong emotional reactions. Once an emotional reaction ensues, the gap between learner reaction and strategy identification remains relatively underexplored. To better understand how learners may identify bias mitigation strategies, the authors explored perspectives of medical students during the clinical portion of their training to the experience of taking the IAT, and the resulting feedback.

METHODS

Medical students in Bronx, NY, USA, participated in one 90-minute session on implicit bias. The focus of analysis for this study is the post-session narrative assignment inviting them to take the race-based IAT and describe both their reaction to and the implications of their IAT results on their future work as physicians. The authors analysed 180 randomly selected de-identified essays completed from 2013 to 2019 using an approach informed by constructivist grounded theory methodology.

RESULTS

Medical students with clinical experience respond to the IAT through a continuum that includes their reactions to the IAT, acceptance of bias along with a struggle for strategy identification, and identification of a range of strategies to mitigate the impact of bias on clinical care. Results from the IAT invoked deep emotional reactions in students, and facilitated a questioning of previous assumptions, leading to paradigm shifts. An unexpected contrast to these deep and meaningful reflections was that students rarely chose to identify a strategy, and those that did provided strategies that were less nuanced.

CONCLUSION

Despite accepting implicit bias in themselves and desiring to provide unbiased care, students struggled to identify bias mitigation strategies, a crucial prerequisite to skill development. Educators should endeavour to expand instruction to bridge the chasm between students' acceptance of bias and skill development in management of bias to improve the outcomes of their clinical encounters.

Medication risk management and health equity in New Zealand general practice: a retrospective cross-sectional study

BACKGROUND

Despite an overt commitment to equity, health inequities are evident throughout Aotearoa New Zealand. A general practice electronic alert system was developed to notify clinicians about their patient's risk of harm due to their pre-existing medical conditions or current medication. We aimed to determine whether there were any disparities in clinician action taken on the alert based on patient ethnicity or other demographic factors.

METHODS

Sixty-six New Zealand general practices from throughout New Zealand participated. Data were available for 1611 alerts detected for 1582 patients between 1 and 2018 and 1 July 2019. The primary outcome was whether action was taken following an alert or not. Logistic regression was used to assess if patients of one ethnicity group were more or less likely to have action taken. Potential confounders considered in the analyses include patient age, gender, ethnicity, socio-economic deprivation, number of long term diagnoses and number of long term medications.

RESULTS

No evidence of a difference was found in the odds of having action taken amongst ethnicity groups, however the estimated odds for Māori and Pasifika patients were lower compared to the European group (Māori OR 0.88, 95 %CI 0.63-1.22; Pasifika OR 0.88, 95 %CI 0.52-1.49). Females had significantly lower odds of having action taken compared to males (OR 0.76, 95 %CI 0.59-0.96).

CONCLUSIONS

This analysis of data arising from a general practice electronic alert system in New Zealand found clinicians typically took action on those alerts. However, clinicians appear to take less action for women and Māori and Pasifika patients. Use of a targeted alert system has the potential to mitigate risk from medication-related harm. Recognising clinician biases may improve the equitability of health care provision.

Physician gender as a source of implicit bias affecting clinical decision-making processes: a scoping review

BACKGROUND

The demographic profile of practicing physicians is changing as more female medical students are graduating and practicing in the field. While the education received may not differ by gender, studies have shown that physician practice outcomes vary by provider gender. Various factors could contribute to these differences, including culture and explicit biases which may lead to implicit bias. This study aims to identify the available evidence of gender-based implicit bias throughout the delivery process of medicine.

METHODS

This scoping review evaluated published literature within the PubMed, Ovid MEDLINE, PsychINFO, Web of Science, and BioMed Central databases pertaining to physician's gender as a factor in the delivery of medicine. Arksey and O'Malley's six-stage methodology was used as a framework and reported using the updated Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Searches occurred between May 2020 and June 2020, and the timeframe was not limited. Included articles had gender as a factor in the delivery of medicine and implicit bias. Articles were excluded if they did not include the gender of the physician. After screening by reviewers and a medical librarian, study characteristics were charted and analyzed.

RESULTS

The initial search resulted in 2420 records. After screening, 162 of the records were selected based on title and keyword relevance. After additional screening, 15 records were ultimately included in the review based on full-text evaluation. Records were organized into sub-topics post hoc focused on clinical qualities, diagnostics, treatment, and outcomes.

CONCLUSION

This scoping review found that gender-based implicit bias may be inadvertently acquired from culture and education. Although implicit bias is highly researched, much of the current literature focuses on the gender of the patient. This study found important gaps in the available literature regarding race and gender of the physician. Further studies could explore outcome differences between recent graduates and career physicians, for both female and male physicians.

The Impact of Racial Bias in Patient Care and Medical Education: Let's Focus on the Educator

INTRODUCTION

Racial bias in health care is well documented. Research shows the presence of racial bias among health care providers. There is a paucity of workshops focused on racial bias effects in health professions educators.

METHOD

Two to three workshops were delivered to a diverse group of clinical educators from three programs at a major academic institution. Each workshop included a brief multimedia presentation followed by a facilitated group discussion. Participants completed the online Implicit Association Test (IAT), a baseline demographic questionnaire, and a brief post-then-pre questionnaire.

RESULTS

Twenty-four faculty participated in the study (six physicians, eight nurse practitioners, 10 physician assistants). Nineteen (90%) were women, 18 (86%) were White, nine (43%) had more than 10 years of experience as educators, and seven (35%) had previously participated in a biases program. Seventeen completed the IAT. Sixteen educators agreed or strongly agreed that bias has a significant impact on patients' outcomes at the end of the workshop compared to 17 before the workshop. Seventeen educators agreed or strongly agreed that recognizing their own racial bias would positively alter their teaching practice after the workshop compared to 15 before the workshop.

DISCUSSION

This series of workshops was created to fill a gap regarding the impact of racial bias on patient outcomes, health disparities, and health professions education. The impact of racial bias in health professions education and the long-term impact of awareness and knowledge of racial bias in education are areas needing further evaluation.

Why do Thoracic Radiologists Need to Know About Cultural Competence (and What Is it Anyway)?

Thoracic radiologists meet patients when performing procedures such as transthoracic computed tomography-guided biopsy and during shared decision-making required for lung cancer screening. Both patients and thoracic radiologists are influenced by their cultures, which affect their health care interactions. While culture may relate to religion or ethnicity of individuals, it also includes multiple additional characteristics such as gender, socioeconomic status, sexual orientation, education, occupation, age, disability, and more. Patients from different cultures undergo similar medical procedures; however, care must be tailored according to the cultural and linguistic needs of each patient. Cultural competence allows all patients, from the same or different culture as the thoracic radiologist, to receive care that is tailored to the patient's cultural and linguistic needs. Cultural competence includes concepts such as cultural awareness, linguistic competence, and health literacy as well as avoiding bias and stereotyping. Culturally competent care requires appropriate services for interpretation, relating to spoken language, and translation, related to written reports and documents. The implications of not providing adequate interpretation and translation services include the inability to take an accurate health history and patient inability to understand the informed consent forms. Thoracic radiologic services should have culturally competent practices in place at every step of the care, starting from the first phone call when patients are making an appointment. This will allow patients to receive care that is culturally and linguistically appropriate and lead to better satisfaction and outcomes.

Acting Wisely: Eliminating Negative Bias in Medical Education-Part 2: How Can We Do Better?

In Part 1 of this 2-article series, the authors reviewed the problem of unmitigated bias in medical education and proposed a wisdom-based framework for a different way of educating medical students. In this article, Part 2, the authors answer a key question: How can medical educators do better? Is a bias-free environment possible? The answer to the latter question likely is "no." In fact, having a zero-bias goal in mind may blind educators and students to the implicit biases that affect physicians' decisions and actions. Biases appear to be a part of how the human brain works. This article explores ways to neutralize their destructive effects by: (1) increasing awareness of personal biases; (2) using mitigation strategies to protect against the undesirable effects of those biases; (3) working to change some negative biases, particularly learned biases; and (4) fostering positive biases toward others. The authors describe the concrete actions-interpersonal, structural, and cultural actions-that can be taken to reduce negative bias and its destructive effects.

The development of an online diversity and inclusion community: Promoting a culture of inclusion within a college of nursing

Societal demographics are rapidly changing and driving the need to develop a culturally aware and sensitive nursing workforce. Nursing faculty are essential to transform academic and healthcare settings into culturally responsive environments. Yet, there isn't a "one size fits all" plan for faculty to foster diversity and inclusion (D&I) within academic nursing. For instance, cultural humility best practices in academia are limited as D&I interventions historically focus on cultural competency. Cultivating cultural humility exceeds developing cultural competency. Cultural humility incorporates elements of self-reflection/critique (acknowledging assumptions and beliefs), learning from others (listening and being open), and partnership-building (gaining appreciation and respect), all of which encompasses a life-long process. The purpose of this paper is to outline the development of an online D&I communication platform for a college of nursing. We present lessons learned and helpful recommendations for others promoting culturally responsive educational environments. This work is important as limited literature exists outlining the development of online communication platforms where faculty, students, and staff can foster cultural humility. Adopting cultural humility into the fabric of the college of nursing can lead to open communication, a greater understanding of one another, and an opportunity to improve relationships with diverse individuals and patient populations.

Culturally aware mentorship: Lasting impacts of a novel intervention on academic administrators and faculty

National efforts to address the diversity dilemma in Science, Technology, Engineering, and Math (STEM) often emphasize increasing numbers of historically underrepresented (HU) students and faculty, but fall short in instituting concrete changes for inclusion and belonging. Therefore, increasing the pool of senior faculty who wish to become guides and advocates for emerging scientists from HU populations is an essential step toward creating new pathways for their career advancement. As a step toward achieving this goal, we created a novel eight-hour intervention on Culturally Aware Mentoring (CAM), a program of the National Research Mentoring Network (NRMN) targeted to faculty and administrators. A previous report of surveys at the end of the CAM sessions revealed substantial awareness and knowledge gains, with participants expressing intentions to use and implement new skills they had learned. In this paper, we provide the results of our thematic analysis of qualitative interviews with academic administrators and faculty, 18-24 months after participation in CAM. Interviews were designed to determine: 1) What changes in self-perceptions and interactions occurred as a result of participation in CAM? 2) What specific components of CAM are associated with changes in individual beliefs and practices? 3) How did participants actively make changes after the CAM workshop? 4) What barriers or challenges do participants encounter after the CAM intervention? The results demonstrate the lasting influences of CAM on participants' awareness of cultural differences, their assumptions about and approaches toward interactions with colleagues and students, and their efforts to change their behaviors to promote inclusive practices in their mentoring and teaching of HU students in STEM. Our findings provide evidence that CAM can be incorporated into existing mentor training programs designed to improve the confidence and capacity of senior research faculty mentors to make culturally-informed, scholar-centered decisions to more deliberately recognize and respond to cultural differences within their mentoring and collegial relationships.

The effects of migrant background and parent gender on child protection decision-making: An intersectional analysis

BACKGROUND

Disparities in decision-making are a recognized concern within child protection systems and imply that marginalized groups are being treated unequally compared to majoritized groups. Previous studies reported that both ethnicity and the gender of the parent that maltreated the child seem associated with an increased likelihood that child protection agencies provide services after an investigation or that children are placed out of their homes.

OBJECTIVE

We investigated whether migration background and the gender of the parent who maltreated the child seem associated with the decision whether a case was opened for continuing services. In addition, we inspected whether the intersections between migration background and parent gender were correlated with disparities in decision-making.

PARTICIPANTS AND SETTING

Our multinational sample consisted of 1189 cases that were involved with child protection agencies in England, the Netherlands, and Germany.

METHODS

We systematically coded and analyzed child protection case files. We conducted logistic regression analysis to investigate for disparities in decision-making.

RESULTS

The intersectional analysis showed that maltreatment committed by mothers (OR = 2.25, p =  .001) and migrant fathers (OR = 2.21, p =  .030) was associated with an increased likelihood to provide ongoing services. However, country specific analyses showed that these effects were most pertinent in the English sample.

CONCLUSIONS

These findings suggest a need to address migration background and gender disparities in child protection practice. Future research could investigate whether other contextual factors (e.g. characteristics of the professional and agency) seem associated with disparities in decision-making.

Implicit Bias in Health Professions: From Recognition to Transformation

Implicit bias recognition and management curricula are offered as an increasingly popular solution to address health disparities and advance equity. Despite growth in the field, approaches to implicit bias instruction are varied and have mixed results. The concept of implicit bias recognition and management is relatively nascent, and discussions related to implicit bias have also evoked critique and controversy. In addition, challenges related to assessment, faculty development, and resistant learners are emerging in the literature. In this context, the authors have reframed implicit bias recognition and management curricula as unique forms of transformative learning that raise critical consciousness in both individuals and clinical learning environments. The authors have proposed transformative learning theory (TLT) as a guide for implementing educational strategies related to implicit bias in health professions. When viewed through the lens of TLT, curricula to recognize and manage implicit biases are positioned as a tool to advance social justice.

Addressing Gender-Related Implicit Bias in Surgical Resident Physician Education: A Set of Guidelines

While it is the goal of academic institutions to train male and female resident physicians equally, gender-related implicit bias may play a role in resident training, thus impacting the quality and fairness of education. Implicit bias may be one of the reasons for the discrepancies that exist in resident training, specifically in learning style, evaluations by faculty members, and treatment of female residents by other clinicians. Patterns of systemic gender-related implicit bias, we argue, remain pervasive in the healthcare system and affect medical education. This review identifies areas of surgical education that are susceptible to gender-related bias and provides recommendations to safeguard gender equity in resident education. We believe behavioral change can help maintain an inclusive learning environment. Using evidence from existing data, we generated guidelines to provide surgical educators in academic centers with information to further understanding of, training in, and steps toward overcoming gender-related implicit bias in resident education. Our guidelines include specific recommendations for educators to require training modules, remove bias from teaching resources, use formal introductory titles, maintain comparable evaluations, encourage women in surgery, adjust instructional methods, and caution self-reporting.

Teaching Cultural Humility and Implicit Bias to Veterinary Medical Students: A Review and Recommendation for Best Practices

Cultural humility, with its concomitant understanding of the importance of the influences of diversity and inclusion, improves health outcomes in the human medical field. Recent changes to the American Veterinary Medical Association Council on Education requirements in veterinary medicine include teaching the impact of implicit bias on the delivery of veterinary medical services. Because overt enhancement of self-awareness is not fodder for traditional veterinary medical education delivery systems, in this article we review existing literature on the impact of recognition of implicit bias on health care and offer insights on ways to help veterinary students learn this skill, drawing on evidence from an inter-professional intervention called WisCARES (Wisconsin Companion Animal Resources, Education, and Social Services).

Does diversity go beyond sex and gender? Gender as social category of diversity training in health profession education - a scoping review

Background: Sex and gender are social categories of diversity. Diversity can be perceived with an intersectional framework as it demonstrates the intersecting categories that might contribute to oppression, inequality, power and privilege. This article focused on what aspects were considered in diversity training programmes for health professions and the role of sex/gender in this context. Method: This scoping review focuses on the social categories mentioned in diversity education of health professionals. Articles on diversity training for health professionals were searched for in the Web of Science database using the keywords gender, diversity, training, education and health professions. Twelve articles were finally included in this review. Thematic analysis was employed to summarise information deduced from articles. Findings: Gaps in the aspects included in diversity training were identified. Findings show that culture was mostly discussed, whereas sex/gender and lesbian, gay, bisexual, transgender, queer and intersex (LGBTQI) were focused on only to a minor extent. Cultural diversity training includes self-reflection on one's own culture, whereas a comparable tool for sex/gender and LGBTQI is missing. Additionally, other social categories of diversity, such as disability or age, are largely absent. Conclusion: Diversity should be incorporated in its full breadth in health profession education and not fragmented. Additionally, other social categories such as gender might benefit from including self-reflection on these categories in addition to reflecting on the role of power and privilege in order to increase self-awareness for diversity. In this way, othering of the population might be prevented and healthcare can be improved for all.

On allegations of invasive species denialism

Science denialism retards evidenced-based policy and practice and should be challenged. It has been a particular concern for mitigating global environmental issues, such as anthropogenic climate change. But allegations of science denialism must also be well founded and evidential or they risk eroding public trust in science and scientists. Recently, 77 published works by scholars, scientists, and science writers were identified as containing invasive species denialism (ISD; i.e., rejection of well-supported facts about invasive species, particularly the global scientific consensus about their negative impacts). We reevaluated 75 of these works but could find no examples of refutation of scientific facts and only 5 articles with text perhaps consistent with one of the 5 characteristics of science denialism. We found, therefore, that allegations of ISD were misplaced. These accusations of science denialism may have arisen because invasion biology defines its subjects-invasive species-based on multiple subjective and normative judgments. Thus, more than other applied sciences its consensus is one of shared values as much as agreed knowledge. Criticisms of invasion biology have largely targeted those subjective and normative judgments and their global imposition, not the knowledge on which the discipline is based. Regrettably, a few invasion biologists have misinterpreted the critique of their values-based consensus as a denial of their science when it is not. To make invasion biology a more robust and widely accepted science and to avoid unnecessary misunderstandings and conflicts, invasion biologists could be more accepting of perspectives originating from other disciplines and more open to values-based critique from scholars and scientists outside their field. This recommendation applies to all conservation sciences, especially those addressing global challenges, because these sciences must serve and be relevant to communities with an extraordinary diversity of cultures and values.

Physician Workforce Disparities and Patient Care: A Narrative Review

Background: Ensuring the strength of the physician workforce is essential to optimizing patient care. Challenges that undermine the profession include inequities in advancement, high levels of burnout, reduced career duration, and elevated risk for mental health problems, including suicide. This narrative review explores whether physicians within four subpopulations represented in the workforce at levels lower than predicted from their numbers in the general population—women, racial and ethnic minorities in medicine, sexual and gender minorities, and people with disabilities—are at elevated risk for these problems, and if present, how these problems might be addressed to support patient care. In essence, the underlying question this narrative review explores is as follows: Do physician workforce disparities affect patient care? While numerous articles and high-profile reports have examined the relationship between workforce diversity and patient care, to our knowledge, this is the first review to examine the important relationship between diversity-related workforce disparities and patient care.

Methods: Five databases (PubMed, the Cochrane Library of Systematic Reviews, EMBASE, Web of Knowledge, and EBSCO Discovery Service) were searched by a librarian. Additional resources were included by authors, as deemed relevant to the investigation.

Results: The initial database searches identified 440 potentially relevant articles. Articles were categorized according to subtopics, including (1) underrepresented physicians and support for vulnerable patient populations; (2) factors that could exacerbate the projected physician deficit; (3) methods of addressing disparities among underrepresented physicians to support patient care; or (4) excluded (n=155). The authors identified another 220 potentially relevant articles. Of 505 potentially relevant articles, 199 (39.4%) were included in this review.

Conclusions: This report demonstrates an important gap in the literature regarding the impact of physician workforce disparities and their effect on patient care. This is a critical public health issue and should be urgently addressed in future research and considered in clinical practice and policy decision-making.

Not missing the opportunity: Strategies to promote cultural humility among future nursing faculty

As the demographics in the United States continue to change, nurses must deliver care to patients from diverse cultural backgrounds. Cultural humility is a lifelong process of self-reflection which is also defined by that individual. It allows an individual to be open to other people's identities, which is core to the nursing standard of providing holistic care. Embracing and incorporating cultural humility is essential for creating a comprehensive and individualized plan of care. One of the ways to achieve cultural humility in nursing is to train future faculty to become agents of cultural humility. This also helps to create a pipeline of nurses who have respect and empathy for the patients they serve. The aims of this paper include: 1) define cultural humility and its importance to healthcare professionals; 2) explore the intrapersonal, interpersonal, and system levels of cultural humility; 3) provide insight on how to promote cultural humility; 4) reflect on best practices across a variety of healthcare disciplines; and 5) provide suggestions for practice.

Health Disparities in the Hospitalized Child

Health care disparities exist along the continuum of care for children admitted to the hospital; they start before admission, impact hospital course, and continue after discharge. During an acute illness, risk of admission, length of stay, hospital costs, communication during family-centered rounds, and risk of readmission have all been shown to vary by socioeconomic status, race, and ethnicity. Understanding factors beyond the acute illness that increase a child's risk of admission, increase hospital course complications, and lower discharge quality is imperative for the new generation of pediatric hospitalists focused on improving health for a population of children. In this article, we describe a framework to conceptualize socioeconomic, racial, and ethnic health disparities for the hospitalized child. Additionally, we offer actions pediatric hospitalists can take to address disparities within their practices.

A Qualitative Study of New York Medical Student Views on Implicit Bias Instruction: Implications for Curriculum Development

BACKGROUND

For at least the past two decades, medical educators have worked to improve patient communication and health care delivery to diverse patient populations; despite efforts, patients continue to report prejudice and bias during their clinical encounters. Targeted instruction in implicit bias recognition and management may promote the delivery of equitable care, but students at times resist this instruction. Little guidance exists to overcome this resistance and to engage students in implicit bias instruction; instruction over time could lead to eventual skill development that is necessary to mitigate the influence of implicit bias on clinical practice behaviors.

OBJECTIVE

To explore student perceptions of challenges and opportunities when participating in implicit bias instruction.

APPROACH

We conducted a qualitative study that involved 11 focus groups with medical students across each of the four class years to explore their perceptions of challenges and opportunities related to participating in such instruction. We analyzed transcripts for themes.

KEY RESULTS

Our analysis suggests a range of attitudes toward implicit bias instruction and identifies contextual factors that may influence these attitudes. The themes were (1) resistance; (2) shame; (3) the negative role of the hidden curriculum; and (4) structural barriers to student engagement. Students expressed resistance to implicit bias instruction; some of these attitudes are fueled from concerns of anticipated shame within the learning environment. Participants also indicated that student engagement in implicit bias instruction was influenced by the hidden curriculum and structural barriers.

CONCLUSIONS

These insights can inform future curriculum development efforts. Considerations related to instructional design and programmatic decision-making are highlighted. These considerations for implicit bias instruction may provide useful frameworks for educators looking for opportunities to minimize student resistance and maximize engagement in multi-session instruction in implicit bias recognition and management.

Perspectives of Patients With Mental Illness on How to Better Teach and Evaluate Diversity Education in the National Health Service

INTRODUCTION

Diversity education is a mandatory requirement for all mental-health practitioners and health care professionals in the UK National Health Service. Wide variability exists in the development, delivery, and evaluation of diversity education across health care settings, with limited evidence to suggest the optimal approach for teaching this subject. This study aimed to explore the perspectives of patients with mental illness on how to better teach and evaluate diversity education in the National Health Service.

METHODS

A participatory research approach was used with five mental-health patient organizations. Forty-two patients with mental illness took part in three participatory workshops. Data were analyzed through template analysis.

RESULTS

The findings indicated that a focus on the nuances and dynamics of clinical relationships would be beneficial. Specifically, the relationship considered most important to examine with respect to diversity education was the "practitioner-self" relationship.

DISCUSSION

Reconstructing the relationship-centered care model with the addition of the practitioner-self relationship may be better suited to theoretically informing future developments in diversity education. Further research is needed to understand what educational approaches contribute toward a relationship-centered care outlook and how relationship building behaviors, particularly those relevant to the practitioner-self relationship are best developed in diverse settings.

Towards a culturally competent health professional: a South African case study

BACKGROUND

South Africa (SA) has a growing multilingual and multicultural population of approximately 55 million people, and faces service delivery challenges due to a shortage in skilled health professionals. Many health care facilities still depict distinct racial and ethnic characteristics that date back to the apartheid era, and there are reports of racial intolerance or preferential treatment at some facilities. There is limited literature in South Africa on cultural competence or on how to train health professionals to provide culturally competent care. This paper describes a study conducted to gain a better understanding of final year medical students' perceptions regarding concepts related to cultural and linguistic competence in the SA healthcare setting.

METHODS

An exploratory, cross-sectional, analytical study used a questionnaire to collect data from final year students at the medical school.

RESULTS

The demographic profile indicated considerable diversity in the respondents for languages spoken, ethnicity and religion. Responses indicated a level of cultural awareness and, according to the Cross Framework, a position of cultural pre-competence. This position was supported by the majority expressing high levels of agreement with the items deemed to indicate responsiveness: a desire for cultural competence to be promoted in the medical curriculum and for professional development to improve delivery of services and support to linguistically and culturally diverse groups. No significant association was found when analysing the latter item against demographic grouping variables. However, although not significant, a diminishing trend emerged in the rankings of monolingualism, bilingualism and multilingualism, suggesting that the ability to speak more than one language could possibly be a facilitating factor in acquiring cultural competence.

CONCLUSIONS

In response, it is recommended that specific learning objectives be included in the medical curriculum. Understanding of concepts related to both individual and institutional cultural competence would improve insights into their relevance in responding to the challenges related to culture in SA healthcare. Further research in teaching cultural competence is recommended. In order to respond to local needs, this should include research at a community level to analyse patients' perspectives and satisfaction with the cultural competence of healthcare providers and organisations serving the SA public.