The Effects of Race and Racial Concordance on Patient-Physician Communication: A Systematic Review of the Literature

International students in United States allopathic medical education: a mixed-methods analysis of institutional policies

International medical students (IMS; non-U.S. citizens/permanent residents) greatly enhance the diversity of U.S. medical schools and serve in areas of greatest healthcare needs. Despite 15% of the US population being foreign born, international students represent < 2% of US-MD matriculants. Factors that contribute to this underrepresentation of IMS remain unknown. In this study, we analyzed the accessibility, quality, and inclusivity of publicly available admissions and financial aid policies at all US-MD schools, with the goal of evaluating potential institutional and informational barriers faced by IMS. Institutional webpages and American Association of Medical College (AAMC) databases were searched from May-July 2023 to gather IMS-specific admissions and financial aid information from 153 accredited US-MD schools. Two-tailed t-test or chi-square analysis was used to examine differences. An inductive thematic approach was used to qualitatively categorize institutional webpage friendliness. While 45% (69/153) of U.S.-MD schools reported accepting IMS, only 18% (27/153) admitted students without restrictions (e.g., Canadians only, state/religious preference). Further, 38% (26/69) of the schools that accept IMS did not provide financial aid information, while nearly two-thirds of the remaining schools required proof of personal financial ability with no institutional/federal support. International students also entered schools with a higher average Medical College Admission Test (MCAT) score and Grade Point Average (GPA). In the national AAMC databases, 19 additional programs were listed as accepting IMS although the institutional webpages stated otherwise; the databases also lacked details on specific restrictions posed by the majority of institutions. Of all 153 webpages, only 14% were deemed 'international friendly.' Restrictive admissions and financial aid policies as well as the poor quality and access to information are major barriers that affect IMS. Strategies that aim to overcome these challenges can greatly help advance diversity, equity, and inclusion in medical education.

Modeling Patterns of Medication Adherence in Primary Open-Angle Glaucoma

Objective

To use group-based trajectory modeling to identify patterns of medication adherence in patients with primary open-angle glaucoma (POAG) and to identify factors associated with each pattern.

Design

Prospective cohort study.

Participants

Seventy-two patients with POAG who were enrolled in a National Institutes of Health-funded progression study at the University of Alabama at Birmingham were included in this study. Patients were required to be >18 years of age, have a diagnosis of POAG, and be prescribed hypotensive eye drops to treat their glaucoma.

Methods

Fifty-two weeks of mean weekly medication adherence data were collected using Medication Event Monitoring Systems. Group-based trajectory modeling was used to estimate models with 2, 3, 4, 5, and 6 medication adherence trajectory groups. Self-reported race and illness perception were included as covariates. The model with the lowest Bayesian information criterion (which provides a measure of the trade-off between model fit and model complexity) and the highest number of clinically relevant trajectory groups was deemed optimal.

Main Outcome Measures

Medication adherence trajectory groups.

Results

The Bayesian information criterion was -1041.1 for the 2-group model, -755.9 for the 3-group model, -643.8 for the 4-group model, -590.4 for the 5-group model, and -559.0 for the 6-group model. We identified the 4-group model as the most optimal. The 4 trajectory groups estimated by this model were near-perfect adherence (51.8% of participants), good adherence (23.2% of participants), declining adherence (18.1% of participants), and poor adherence (6.9% of participants). Compared with the poor adherence group, a higher illness perception score predicted a lower probability of membership in the good (B = -0.276, P = 0.042) and declining (B = -0.303, P = 0.028) adherence groups.

Conclusions

Medication adherence is an important clinical outcome that is associated with disease severity and disease progression in POAG. Further investigation of this important topic may reveal other shared clinical characteristics that can be used to identify patients who may be at risk for adverse clinical outcomes such as glaucoma progression.

Financial Disclosures

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Beyond diversity recruitment: Next steps to ensure that underrepresented emergency medicine residents thrive

A diverse workforce in emergency medicine (EM) aims to improve patient care by addressing racism in health care, increasing representation in medicine, and improving the quality of training for all residents. Many EM residency programs have launched recruitment efforts to attract residents from diverse backgrounds. However, recruitment efforts only represent the first step in building a culturally responsible workforce. Trainees who are underrepresented in medicine must be welcomed into an inclusive training environment that has been thoughtfully constructed before they arrive. This type of supportive environment can be achieved by shifting away from majority-serving ideals and building an informed infrastructure that functions to help all trainees succeed. We expand upon challenges and areas of opportunity at the individual, departmental, and institutional levels and describe common pitfalls when trying to create inclusive spaces for residents including lack of vision alignment, inadequate financial investment, and performative allyship. We also propose strategies that focus specifically on actionable changes that residency program, departmental, and institutional leadership can implement to mitigate these challenges.

ARIE: A Health Equity Framework for Public Health Interventions Informed by Critical Race Theory and Critical Gerontology

Older racialized minorities were particularly vulnerable during the last pandemic due to the interlocking influences of structural racism and ageism, which are often disregarded in public health planning. This oversight not only compromises the social justice and health equity goals of public health efforts but it also calls for a more inclusive approach that systematically addresses these deficiencies at every stage of a public health response. To achieve this, we propose Age- and Race-conscious Interventions done Equitably (ARIE), a novel analytical framework grounded in critical race theory and critical gerontology. ARIE is based on a four-step approach, which aligns with different stages of public health interventions. It will help ensure that structural discrimination influencing access to healthcare resources during a biological event is not ignored, and that public health authorities work actively toward identifying and addressing ageist and racist biases in their response plans and interventions.

Disparities in Patient Demographics at a Student-Run Free Clinic: Comparing Clinic Utilization to City, State, and National Trends

BACKGROUND

With 8.4% of Americans uninsured, free clinics serve as essential safety nets for underserved populations. This study compared the demographics of the patients of a student-run free to Toledo, Ohio, and national census data to evaluate health needs, barriers to care, and the characteristics of the underserved population.

METHODS

A retrospective review of 1,338 visits across five clinic sites was conducted from February 2023 to February 2024. Demographic variables, including race, insurance, education, sex, and primary language, were analyzed and compared to 2020 Census data from Toledo, Ohio, and the United States.

RESULTS

Compared to Toledo, the clinic served 22.63% fewer White patients, 17.27% more Hispanic/Latino patients, and 5.62% fewer African American patients. Among clinic patients under 65 years, 61.91% were uninsured, compared to 8.3% in Toledo and 10.2% nationally. Non-English speakers were overrepresented (33.4% vs. 6.8% in Toledo and 9.5% nationally), with Spanish speakers making up 21.72% of clinic patients compared to 3.2% in Toledo. Educational attainment differed slightly, with fewer high school graduates (82.97% vs. 87.10% in Toledo) but more individuals with higher education degrees (27.10% vs. 19.6% in Toledo and 25.6% nationally).

CONCLUSIONS

This study underscores the demographic differences between CCC patients and city, state, and national populations, offering insight into the populations most reliant on free clinics. Policymakers and public health agencies must consider these disparities to tailor interventions addressing healthcare access and social determinants of health.

Barriers to Health Care Access and Use among Racial and Ethnic Minorities with Noninfectious Uveitis

PURPOSE

To investigate barriers to health care access and use among patients with noninfectious uveitis (NIU) across different racial and ethnic groups.

DESIGN

Retrospective cross-sectional study.

PARTICIPANTS

Participants in the nationwide All of Us Research Program who received a diagnosis of chronic NIU.

METHODS

We analyzed the health care access and use (HCA&U) and social determinants of health (SDoH) surveys. Racial and ethnic groups were defined as non-Hispanic White, non-Hispanic Black, Hispanic, and other. Multivariable logistic regression models adjusted for age, sex, education, insurance type, and income were used to assess disparities.

MAIN OUTCOME MEASURES

Financial and nonfinancial disparities in health care access among racial and ethnic groups.

RESULTS

Of 2452 patients with NIU, 810 patients (33%) responded to the HCA&U survey and 607 patients (24.7%) responded to the SDoH survey. Non-Hispanic Black participants reported significantly more experiences of being treated with less courtesy (adjusted odds ratio [aOR], 2.6; 95% confidence interval [CI], 1.4-5; P = 0.003) and respect (aOR, 2.6; 95% CI, 1.4-4.8; P = 0.003), as well as receiving poorer services (aOR, 3.6; 95% CI, 1.9-6.9; P < 0.001) compared with non-Hispanic White participants. Individuals categorized as belonging to other minority groups were more likely to delay seeking medical care because of out-of-pocket costs (aOR, 3.4; 95% CI, 1.6-7.1; P = 0.001) and concerns over medical bills (aOR, 2; 95% CI, 1.05-3.8; P = 0.04). Additionally, they experienced significant delays in care because of living in rural areas with limited access to health care providers (aOR, 7.1; 95% CI, 1.4-35.6; P = 0.02).

CONCLUSIONS

Racial and ethnic minorities with NIU face significant barriers to health care use and quality, underscoring the need for targeted interventions to address disparities and improve health equity in uveitis management.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Patient-Physician Racial Concordance Increases Likelihood of Total Knee Arthroplasty Recommendation

BACKGROUND

Minority patients have been shown to underutilize total knee arthroplasty (TKA) compared to non-Hispanic White patients. Specific drivers of this underutilization have not been identified. We sought to determine if racial concordance between patient and physician is associated with the surgeon's likelihood to recommend TKA.

METHODS

There were 402 patients who presented for management of knee osteoarthritis to the clinics of four fellowship-trained arthroplasty surgeons at a single academic center. We recorded the patient and surgeon's race/ethnicity as well as the physician-recommended treatment. Patient clinical data was input to the American Academy of Orthopaedic Surgeons (AAOS) appropriate use criteria website to generate a guideline-based procedure recommendation for TKA. Patients who were not appropriate for TKA based on AAOS guidelines were excluded from analyses to minimize selection bias. Chi-square and multivariable regression analyses evaluated the relationship between TKA recommendation by surgeon and physician-patient racial concordance.

RESULTS

Patients in this cohort who experienced racial concordance with their surgeon were more likely to receive a recommendation for TKA than patients who experienced racial discordance. Black patients who received racially concordant care were more likely to be offered surgery compared to those who received racially discordant care (55.1 versus 23.0%, P = 0.0001). The same effect was not observed in non-Hispanic White patients, where there was no significant difference in surgery offers between patients who received concordant versus discordant care (P = 0.18). Multivariable analyses were also conducted to test factors associated with TKA recommendations. Racial concordance was found to be an independent predictor of TKA recommendation while controlling for patient factors and individual differences by the surgeon.

CONCLUSIONS

Patients receiving racially concordant care in this cohort were more likely to be offered TKA, and the effect of racial concordance on TKA recommendation was greater among Black patients. These findings provide insight into possible drivers of TKA underutilization among minority groups.

Understanding facilitators and barriers to genetic testing for black ovarian cancer patients: A qualitative study utilizing interview data with patients and providers

Studies consistently demonstrate that Black ovarian cancer patients are less likely to receive guideline-recommended genetic testing. The current study explored barriers to genetic testing among Black women from the perspective of key stakeholders. We conducted semi-structured interviews with patients (n = 5), advanced practice providers (n = 4), genetic counselors (n = 5), and physicians (n = 6). A framework analysis was used to identify themes. All patients identified as Black and completed genetic testing. Among providers, 13% identified as Black and the majority (66%) focused on gynecologic cancer care. Four themes emerged, and the first was that participants felt all women are too overwhelmed by their cancer diagnosis to prioritize genetic testing. However, Black women experience additional stress from racism that adds an additional barrier to genetic services. Second, Black women are unable to access genetic testing due to socioeconomic disadvantages related to a long history of structural racism. Third, Black women may be unwilling to complete genetic testing due to mistrust of providers and the healthcare system. Finally, Black women are less likely to receive genetic services prior to their cancer diagnosis due to cultural barriers and provider misconceptions about Black women's hereditary risk. Our findings highlight barriers to genetic counseling and testing among Black women, which may include individual and structural racism as well as bias. To increase uptake of genetic testing, it is critical for providers to prioritize communication and patient education that is culturally responsive to the needs of Black women and offer social supports to help Black women navigate their cancer care.

The Impact of Language Discordance on Acquiring Broad Social History: A Qualitative Study of Patients, Clinicians, and Interpreters

BACKGROUND

By acquiring a broad social history (BSH), which includes aspects of patients' social needs in addition to their hobbies and activities, values, and perspectives on care, clinicians can provide more patient-centered care, which is known to improve health outcomes. However, the impact of patient-clinician language discordance on acquisition of BSH has not been well studied.

OBJECTIVE

To ascertain whether language discordance impacts clinicians' acquisition of patients' BSH by interviewing patients, clinicians, and medical interpreters.

DESIGN

Qualitative study based on semi-structured interviews, followed by thematic analysis using rapid qualitative data analysis methods.

PARTICIPANTS (OR PATIENTS OR SUBJECTS)

We interviewed 8 Spanish-speaking and 5 English-speaking patients seen for primary care within a public hospital in San Francisco, 6 primary care clinicians, and 8 medical interpreters.

APPROACH

All interviews were recorded and transcribed. The transcriptions were summarized into domains using rapid qualitative data analysis. The summaries were displayed in a matrix and used to generate themes and subthemes.

KEY RESULTS

Analysis of interviews highlighted two overarching themes concerning BSH acquisition. One theme was the importance of BSH: namely, it is critical for patient-clinician relationships and personalized care. Commonly elicited BSH facets were social drivers of health, but leisure activities were less frequently asked. The second theme described ways in which language discordance, via the need for interpretation, affects the collection of BSH, both through increasing time pressure, and hindering rapport-building strategies. Cultural barriers pose an obstacle to BSH acquisition and may operate independently of language discordance.

CONCLUSIONS

Our results suggest two action steps for health systems: (a) apportioning more time for language-discordant visits to increase rapport-building and BSH acquisition, and (b) increasing training for clinicians on acquiring BSH when working with interpreters. Further research is needed to investigate the relationship between language discordance, acquisition of BSH, and patient outcomes.

Adherence Labeling: Understanding the Origins, Limitations, and Ethical Challenges of "Diagnosing" Nonadherence

Promoting adherence to medical recommendations remains one of the oldest yet most persistent challenges of modern clinical practice. Although increasingly sympathetic to structural forces that affect health behavior, standard models frequently conceptualize nonadherence as a phenomenon of patient behavior, a self-evident quality belonging to patients that is responsible for a myriad of undesired outcomes. We contend, however, that this approach not only fails to consider the role of the clinician in the concept's origins in clinical encounters, but also has facilitated the use of adherence terms (eg, nonadherent, noncompliant, treatment resistant) as pejorative social labels to the detriment of the physician-patient relationship. Used without care, such terminology can alter the meaning assigned to patients' behaviors so that structural barriers to care such as poverty and systemic racism are reframed as problems of poor attitude or effort. This article explores the functions of adherence terms as social labels by reviewing their underlying logic in clinical settings and outlining pitfalls in the pathologization of nonadherence in research and practice. We propose the concept of adherence labeling-the assessment, classification, and dissemination of clinicians' perceptions of patients' adherence through social labels-as an alternative model to understand how adherence terms may inadvertently obstruct the care of marginalized patients.

Broadening Inclusion of Primary Care: Trainee Insights and Commentary on Diversity, Equity, and Inclusion

We, as the current and immediate-past NAPCRG Trainee Committee, share our perspectives as an international and diverse group of primary care research trainees. In this essay, we discuss the challenges and opportunities for achieving a more diverse, equitable, and inclusive primary care workforce by reflecting on 2 main challenges: (1) insufficient support for underrepresented identities in medicine, and (2) inadequate integration within existing primary care teams. Within each of these challenges, we pose potential opportunities for improvement using a trainee lens.

Toward Automated Detection of Biased Social Signals from the Content of Clinical Conversations

Implicit bias can impede patient-provider interactions and lead to inequities in care. Raising awareness is key to reducing such bias, but its manifestations in the social dynamics of patient-provider communication are difficult to detect. In this study, we used automated speech recognition (ASR) and natural language processing (NLP) to identify social signals in patient-provider interactions. We built an automated pipeline to predict social signals from audio recordings of 782 primary care visits that achieved 90.1% average accuracy across codes, and exhibited fairness in its predictions for white and non-white patients. Applying this pipeline, we identified statistically significant differences in provider communication behavior toward white versus non-white patients. In particular, providers expressed more patient-centered behaviors towards white patients including more warmth, engagement, and attentiveness. Our study underscores the potential of automated tools in identifying subtle communication signals that may be linked with bias and impact healthcare quality and equity.

Digital Disparities in Healthcare: A Tale of the Haves and Have-Nots?

While the digitalization of healthcare and the advent of consumer-centered technologies have led to advancements in patient engagement, it is evident that certain, underprivileged segments of society might not be benefiting. The purpose of this review was to thus analyze the expanding data focusing on digital disparities in healthcare and was designed based on the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) statement. First, a literature search of original, peer-reviewed publications was undertaken to identify studies pertaining to disparities in the utilization of digital technologies in healthcare using a variety of customized retrieval terms. Articles published from January 2014 to January 2024 were included. Subsequently, a total of 247 peer-reviewed studies were identified which were used to construct a framework for interpretation. The core themes could broadly be categorized into digital health portals (N = 74), telemedicine (N = 57), healthcare wearables (N = 49), digital intervention tools (N = 35), and virtual education (N = 32). While the potential of digital health to fundamentally transform the nature of patient-centric care is increasingly being recognized, the growing "digital divide" between the "haves" and "have-nots" with respect to nearly every facet of technology implementation raises concern regarding the perpetuation of inequities across society.

Stroke prophylaxis after US emergency department diagnosis and discharge of patients with atrial fibrillation and flutter from 21 hospitals

BACKGROUND

Oral anticoagulation (OAC) reduces stroke and mortality risk in patients with non-valvular atrial fibrillation/flutter (AF). Patterns of OAC initiation upon discharge from US emergency departments (ED) are poorly understood. We sought to examine stroke prophylaxis actions upon, and shortly following, ED discharge of stroke-prone AF patients.

METHODS

We included all adults with a primary diagnosis of non-valvular AF, high stroke risk (CHA2DS2-VASc ≥ 2), low/intermediate bleeding risk (HAS-BLED < 4), and no recent (< 90 days) OAC at discharge from 21 community EDs (2010-2017). Annual rates of appropriate stroke prevention action (OAC Action) were calculated for eligible discharges and as defined as an OAC prescription or anticoagulation management service consultation within 14 days of ED discharge. We modeled OAC Action using a parsimonious Poisson regression with identity link adjusting for sex, age, race/ethnicity, stroke risk score (CHA2DS2-VASc), year of visit, provider race/ethnicity, number of ED beds, and presence of an outpatient observation unit, with the patient as a random effect.

RESULTS

We studied 9,603 eligible ED discharges (mean age 73.1 ± 11.4 years, 62.3% female), and mean CHA2DS2-VASc score 3.5 ± 1.5. From 2010 to 2017, OAC Action increased from 21.0% to 33.5%. Factors associated with lower OAC initiation included the following: female sex (-3.6%, 95% CI -5.4 to -1.9), age ≥ 85 vs < 64 years (-3.8%, 95% CI -6.7 to -1.0%), ED beds, n = 20 to 29 (-5.3%, 95% CI -8.36 to -2.4%), 30-49 (-3.8, 95% CI -6.5 to -1.2%), and 50 + (-7.1%, 95% CI -10.6 to -3.7%); with referent being the male sex, < 40 years, and fewer than 20 beds (18.1%, 95% CI 12.8 to 23.4). OAC initiation in 2017 was greater than in 2010 (16.0%, 95% CI 12.3 to 19.7%).

CONCLUSION

Within a community-based ED population of AF patients at high stroke risk, rates of appropriate stroke prevention action increased over the 7-year study period. Rates of AF thromboprophylaxis may be improved by addressing sex and age disparities, as females and those age ≥ 75 were less likely to receive indicated stroke prevention.

'A perfect match': how hematologists discuss donor options and risks with black and white patients considering allogeneic stem cell transplant

Patients of racial minorities have lower chance of securing a suitable donor, essential part of successful allogeneic stem cell transplant. In this simulated interview study, we sought to examine how hematologists discuss donor options and risks with patients with high-risk myeloid neoplasm considering transplant. Thirty-seven US hematologists participated (65% male; 65% white, 24% Asian, none Black), randomly assigned to meet with a Black or white patient actor. The hematologists emphasized the benefits of a full match with the white patient and high chance of securing a donor. Conversely, with the Black patient, they tended not to ask about ancestry, discuss the donor registry, race implications or challenges with donor search. Knowing the patient had children, many recommended haploidentical transplant. The unique circumstances of transplant argue for a focused communication including discussing race. While conversations should be tailored to each patient, limiting essential information on donor options may contribute to disparities.

The ethnogeriatric imperative: strategies for increasing Black physician representation in geriatric medicine

The increasing diversity of the aging population in the United States underscores an urgent need for a more racially and ethnically diverse geriatric physician workforce. Recent statistics reveal a positive relationship between physician-patient racial concordance, life expectancy and health outcomes of Black Americans. Despite this need, Black physicians, as a subgroup, remain significantly underrepresented in geriatric medicine. In this paper, we submit that the ethnogeriatric imperative is a useful framework for developing strategies to increase the representation of Black geriatricians in the U.S. We offer strategies to accomplish this goal: enhancing mentorship and developing career pathways early on during the undergraduate, pre-medicine years. By acknowledging the existing challenges facing geriatrics, we can develop recruitment and retention interventions that move toward a more inclusive field, one that advances health equity.

Information provision in life-threatening illnesses: comprehensive framework

BACKGROUND

In life-threatening illnesses, open information provision can benefit patients and families. However, not all patients prefer to have all information. There is a lack of clinical guidance on how to handle patient preferences for non-disclosure.

AIM

To develop a conceptual framework and practical guidance for clinicians regarding the spectrum of patients' information provision preferences with a focus on when patients do not desire to have full information.

METHODS

Multidisciplinary expert stakeholder meeting.

RESULTS

20 expert stakeholders from various disciplines and continents participated in the expert meeting. Based on the qualitative results, a conceptual framework was created. Our framework highlights that information is never value-free but attains value via healthcare provider and patient/family factors, including how information is interpreted by clinicians and patients/families. In this process, ethical and sociocultural tensions can arise, such as between patient and family autonomy, that can influence harmful effects of the attained value of information along several axes such as empowerment versus disempowerment. To mitigate tensions and minimise harm, our framework produces practical guidance for clinicians such as making a connection and having an open attitude.

CONCLUSIONS

Our framework has clinical, research and policy implications and can be further refined and tested. Ultimately, it serves as a starting point to reduce social and cultural inequities in end-of-life care information in a global context.

"The doctor will see you now… but not for long": Linking physicians' racial attitudes and patients' discrimination experiences to racial disparities in the duration of medical consultations

OBJECTIVE

To investigate the relationship between non-Black physicians' racial attitudes, Black patients' discrimination experiences, and consultation duration in diverse clinical settings.

METHODS

Secondary analyses were conducted on data from three prior studies involving non-Black primary care physicians (Study 1: n = 14, Study 2: n = 5) and their Black patients (Study 1: n = 118, Study 2: n = 31), as well as 15 non-Black oncologists and their 72 Black patients (Study 3). Data included physician and patient surveys, along with video-recorded consultations.

RESULTS

Study 1 revealed that, relative to other physicians, physicians whose racial attitudes fit an aversive racist profile (i.e., low explicit racial bias, high implicit bias) had longer consultations with Black patients who reported more (vs. fewer) discrimination experiences. Study 2 and 3 found that physicians' implicit racial bias is negatively associated with consultation duration. Finally, a meta-analysis supported the effects of aversive racism and patients' discrimination experiences on consultation duration.

DISCUSSION

These findings demonstrate how physicians' racial attitudes and patients' discrimination experiences can affect medical consultation duration-an important aspect of patient-provider communication quality.

PRACTICAL VALUE

These results provide initial evidence for the importance of helping physicians manage the negative consequences of their implicit bias within the current structural constraints of limited medical consultation time and empowering Black patients to advocate for their healthcare needs.

Stigma towards functional disability and anxiety among patients with cancer: The moderating role of physicians' behaviors

OBJECTIVE

To explore the moderating role of physicians' behaviors in medical encounters with cancer patients in the association between physicians' public stigma towards functional disability and post-meeting patient anxiety.

METHODS

A three time-point prospective nested study was conducted between November 2019 and July 2022 in two medical centres. Before the medical encounters, 32 physicians completed the Disability Attitudes in Health Care Scale, and 150 adult cancer patients completed the State-Trait Anxiety Inventory (STAI), pre and post medical encounters. During the medical encounters, structured 'real-time' observations of the physicians' behaviors were recorded using the Four Habits Coding Scheme.

RESULTS

The mixed linear analysis model revealed that the two-way interaction between stigma towards functional disability and physicians' communication behaviors was significantly associated with post-meeting anxiety (b=.161, p < .05). When physicians' behaviors were more negative, the association between physicians' stigma and patients' post-meeting anxiety was stronger. Additionally, pre-meeting anxiety was positively associated with post-meeting anxiety (b=.578, p < .01).

CONCLUSIONS

The findings highlight the positive effect of stigma and the importance of physicians' communication behaviors in alleviating patients' anxiety associated stigma towards functional disability.

PRACTICE IMPLICATIONS

Healthcare training programs should address stigma and develop protocols encouraging healthcare professionals to request patients' to share their specific needs.

Malaria risk perceptions and barriers for effective prophylaxis among sub-Saharan African 'visiting friends and relatives' travellers in Hamburg, Germany

BACKGROUND

The African visiting friends and relatives (VFR) community in the Global North is at high risk of contracting preventable travel-associated infections including malaria when travelling to sub-Saharan Africa. This study aimed to assess barriers to effective prevention and to develop tailored travel counselling.

METHODS

A questionnaire-based survey was conducted from January to August 2023 at the Hamburg Airport among adult sub-Saharan African VFR travellers returning from malaria-endemic destinations in Africa to assess malaria risk perceptions, attitudes towards prophylaxis and counselling and their experiences with travel medicine and malaria prophylaxis.

RESULTS

A total of 389 participants completed the survey. Of these, 67 % (n = 261) demonstrated adequate knowledge of malaria transmission. Fifty-one percent (n = 198) perceived minimal risk of contracting malaria in the malaria-endemic country leading to lower uptake of prophylaxis. Ten percent (n = 37) mistakenly believed they were vaccinated against malaria. Approximately half of the respondents did not seek medical travel advice prior to departure or take antimalarial prophylaxis due to perceived minimal risk of disease. Of those who took antimalarial drugs, 77 % (n = 149) completed the full course. On return, 5 % (n = 20) of the respondents had malaria-like symptoms and of these, 55 % (n = 11) either self-medicated or did not seek medical treatment.

CONCLUSIONS

VFR travellers mistakenly perceive a low risk of malaria, resulting in low uptake of travel medical advice and chemoprophylaxis. Mistrust of advice from healthcare providers was found. Insights from this survey are valuable for practitioners and travel medicine clinics to provide more tailored and culturally sensitive travel advice to VFR travellers.

Trends in Racial and Ethnic Differences in Declined Surgery for Resectable Malignancies in the United States

OBJECTIVE

To assess trends in patients' decisions to decline cancer surgery in the United States by race and ethnicity.

BACKGROUND

Racial and ethnic differences in declining potentially curative cancer surgery are suggested to be due to systemic inequities in health care access and mistrust of health care systems, among other factors. Despite ongoing national efforts to address these inequities, it is unknown whether differences in rates of declined cancer surgery have improved.

METHODS

Using population-based data from the U.S. Surveillance, Epidemiology, and End Results program from 2000 to 2019, we studied individuals with nonmetastatic cancer who were recommended surgery. Racial and ethnic differences in risk-adjusted rates of declined surgery were evaluated by year and cancer site using mixed-effect logistic regression.

RESULTS

Of 2,740,129 patients with resectable, nonmetastatic cancer, Black patients had the highest rates of declined surgery [2.10% (95% CI: 1.91% to 2.31%)], whereas White patients had the lowest [1.04% (95% CI: 0.95% to 1.14%)]. From 2000 to 2019, racial and ethnic differences in declined surgery did not change significantly, except for a decrease in the difference between Hispanic and White patients [difference-in-difference, -0.4% (95% CI: -0.71% to -0.09%)]. When stratified by cancer site, Black-White differences in rates of declined surgery decreased significantly (but were not eliminated) for 4 of 15 sites (esophageal, pancreatic, lung, and kidney; P < 0.001).

CONCLUSIONS

Patients from racial and ethnic minority groups were more likely to decline surgical intervention for potentially curable malignancies, and these differences have persisted over time. Further work is needed to understand the causes of these differences and identify opportunities for improvement.

Patient-Provider Prenatal Nutrition Conversations Using a Human Factors Approach

OBJECTIVE

To examine patient-provider nutrition conversations at initial prenatal visits.

DESIGN

Convergent mixed methods observational study.

SETTING

Two large metropolitan clinics in the midwestern United States.

PARTICIPANTS

Sixteen providers and 20 racially diverse pregnant women.

METHODS

Guided by the Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 model, we observed and audio-recorded initial prenatal visits with obstetric providers. Patients completed post-visit surveys and interviews, and providers completed post-visit interviews. Finally, we sent a practice-wide electronic survey to all providers. We completed quantitative data analysis for descriptive statistics of observation and survey results. We completed qualitative thematic analysis of visit and interview transcripts and combined and categorized results into components of the SEIPS 2.0 model.

RESULTS

We identified multiple dynamic and interacting factors relevant to the work system and processes in the SEIPS 2.0 model in patient-provider conversations about nutrition. Although nutrition was covered in all visits, most conversations were provider-centered and covered basic, general recommendations related to a limited number of topics. Few individualized collaborative discussions that addressed contextual factors occurred.

CONCLUSION

Finding ways to incorporate and address contextual factors into patient-centered conversations about nutrition is vital to optimize the dietary habits of women, especially those from vulnerable populations. To do this, multidisciplinary teams that include nurse practitioners, nurses, obstetricians, and registered dietitians who can address the multiple social determinants of health that affect dietary choices are needed.

Do Patient-Provider Therapeutic Connections Vary by Race or Ethnicity? A Comparison of Black, White, and Hispanic/Latino Patient Experiences

GOAL

This study aimed to determine whether patients who identify as Black/African-American or Hispanic/Latino have different expectations for and experiences of therapeutic connections (TCs) with care providers, compared to those who identify as non-Hispanic White. Although race-based health disparities have been recognized in the United States for decades, efforts to reduce them have yielded inconsistent results. Early evidence suggests that high-quality TCs have important impacts on patient outcomes, which could help explain the persistence of certain disparities.

METHODS

Primary data were collected during a field study that recruited patients from across the U.S. (N = 1,598). We used a cross-sectional online survey of non-Hispanic Black, non-Hispanic White, and Hispanic or Latino (any race) adults who had a healthcare encounter in the previous six months. The sampling strategy oversampled Black and Hispanic/Latino patients and balanced respondents across age groups. The survey asked respondents questions about their expectations for ideal TCs, TC experiences, and satisfaction with their main care provider. Our large sample enabled subgroup analyses that examined the experiences of those with certain intersectional identities (e.g., race and gender). Variables were examined using omnibus analysis of variance with Fisher's least significant difference post hoc tests to compare specific groups.

PRINCIPAL FINDINGS

There were no differences between groups regarding their expectations for ideal TCs. There were, however, differences by race/ethnicity in TC experiences and satisfaction. Differences were more prevalent in subgroup analyses. Chronic conditions, gender, and racial concordance with the provider mattered for some measures but not for others. Generally, Hispanic or Latino patients reported significantly lower levels of experienced TCs.

PRACTICAL APPLICATIONS

Understanding the differences in experiences of care and patient satisfaction by race/ethnicity can facilitate the cultivation of targeted interventions and policies aimed at addressing disparities in healthcare delivery and further promote equitable care for all patients. Nevertheless, more must be done to understand what might lead to poorer TCs for some who identify with marginalized groups and whether poorer TCs lead to poorer health outcomes.

Supervisor Authority and Its Impacts on Equity, Diversity, and Inclusion in National Collegiate Athletic Association Athletic Training Environments

CONTEXT

The demographic landscape of the United States is changing daily, and the demand for representation in today's workforce is both a moral and practical imperative for creating workplaces diverse in thought, expression, and people.

OBJECTIVE

The purpose of this study was to investigate workplace culture and the direct and indirect influence of supervisors on inclusion of minoritized communities, including those who have experienced marginalization for race, ethnicity, religion, national origin, age, marital status, ability, sexual orientation, sex, gender, gender identity and expression, socioeconomic status, spirituality, political affiliation, literacy, or the intersectionality of multiple identities.

DESIGN

Consensual qualitative research study.

SETTING

Semistructured interview.

PATIENTS OR OTHER PARTICIPANTS

Eighteen participants were recruited through direct contact via their public domain email addresses that are located on college/university websites.

DATA COLLECTION AND ANALYSIS

Demographic data were collected through a web-based recruitment survey, which was also used to schedule a semistructured interview. We used the multiphased consensual qualitative research tradition to identify domains and categories representative of the data.

RESULTS

Three domains emerged. The environment domain spoke to the culture each supervisor created through relationship building and intention; intention was further characterized as active or passive behaviors whereby almost all participants described both. Only one-third of participants referenced diversity, equity, inclusion, and accessibility policies and procedures within their organization. The resources domain represented the existence and awareness of organizational diversity, equity, inclusion, and accessibility resources, or lack thereof. The perceptions domain characterized the beliefs of the supervisors relative to diversity, equity, inclusion, and accessibility.

CONCLUSION

Structural efforts must include the creation and implementation of policies and procedures for employee inclusion, not just patient inclusion. The awareness and use of organizational resources is an important component to support supervisor efforts and should be leveraged from within the unit.

Racial equity in and through medical interaction scholarship: A scoping review

OBJECTIVE

We conducted a systematic scoping review to characterize the landscape of communication scholarship within racial health equity in and through the patient-provider interaction.

METHODS

We employed three waves of data collection to identify relevant articles (N = 454) about racial equity within provider-patient interactions. We iteratively developed a codebook concerning article characteristics, coding for journal names, data source, descriptive characteristics for the study samples, and presence of theory and equity in sections of the manuscripts.

RESULTS

This search identified studies (N = 206) that were published in 76 peer-reviewed scientific journals. The majority of studies reported primary data analyses and used survey and interview methodology. Many studies examined participants as patients generally rather than in reference to particular health conditions. Among those with a specific health condition, the largest proportion focused on cancer control. Very few studies included samples with Native American and Pacific Island heritage. Most studies included cisgender men and/or women, but none included transgender men or women. The vast majority of research focused on the patient experience; few centered on providers' and caregivers' experiences. The body of scholarship was largely atheoretical; the most frequently noted constructs were patient-provider communication (including patient-centered communication and patient-centered care), implicit/explicit racial bias, shared decision-making. There was wide variation in the extent to which equity was woven through the manuscripts. Equity is typically mentioned in the literature review, and racial identity in the sample may serve as a marker of racialized experiences.

CONCLUSION

This study demonstrates the need for the development of theory that elevates the centrality of health equity to attend to the bi- or multi-directional flow of communication that shapes the quality of these interactions.

PRACTICE IMPLICATIONS

These insights can serve as a strong foundation for the development of interventions to address equity in clinical interactions.

Uncovering Structurally Differential Care: Pediatric Oncology Nurses' Perspectives Caring for African American Families

BACKGROUND

Psychosocial intervention studies aimed at reducing stress among parents of children with cancer have historically included insufficient samples of African American parents. Pediatric oncology nurses are uniquely positioned to identify and address parent psychosocial needs. However, research exploring their perspectives to serve as psychosocial interventionists specifically for African American families of children with cancer is limited.

OBJECTIVE

To explore the perspectives of pediatric oncology nurses on their role as psychosocial interventionists for African American families navigating childhood cancer.

METHODS

We conducted 32 remote individual interviews and 2 focus groups (n = 4 each) with 40 pediatric oncology nurses from three pediatric cancer centers and a large pediatric oncology nursing organization. Using Corbin and Strauss' Grounded Theory methodology, we used constant comparative analysis to generate a theory based on the nurses' perspectives.

RESULTS

Our emergent theory-Structurally Differential Care-had two major themes (psychosocial resource facilitators and psychosocial resource obstructors). Psychosocial resource facilitators: 1) appreciating families' experiences, 2) longitudinal presence, 3) open communication, 4) holistic care, and 5) safe spaces mitigated structurally differential care. Nurses also identified: 1) difficulty with serious illness conversation, 2) lack of nursing experience, and 3) competing work demands as psychosocial resource obstructors that intensify structurally differential care.

CONCLUSION

This sample of pediatric oncology nurses described experiences that either bolstered or obstructed their psychosocial care provision, signaling potential opportunities for nurse-targeted interventions that may reduce factors contributing to disparities in the psychosocial care for African American families of children with cancer.

Understanding the Medical Education Experiences of Low-Income Students Through a Maslow's Hierarchy of Needs Lens: An Exploratory Qualitative Study

BACKGROUND

Diversity in the physician workforce is critical for quality patient care. Students from low-income backgrounds represent an increasing proportion of medical school matriculants, yet little research has addressed their medical school experiences.

OBJECTIVE

To explore the medical school experiences of students from low-income backgrounds using a modified version of Maslow's Hierarchy of Needs (physiologic, safety, love/belonging, esteem, and self-actualization) as a theoretical framework.

DESIGN

We conducted an exploratory qualitative study through in-depth, semi-structured interviews.

PARTICIPANTS

Forty-two low-income medical students attending US-based MD or DO degree-granting institutions.

APPROACH

We conducted a content analysis of interview transcripts using deductive and inductive coding. We discussed our independent analyses to reach consensus and shared findings with a subgroup of participants for member checking.

RESULTS

Participants described substantial challenges in meeting their basic needs. Unmet physiologic needs included food insecurity, lack of adequate sleep/rest, and poor mental health. Unmet safety needs included lack of reliable transportation and safe housing; threats to financial safety included debt and an inability to cover both medical education-related and non-medical education-related expenses. Unmet belonging needs included difficulty connecting with peers or participating in financially inaccessible social activities. Unmet respect/esteem needs stemmed from bias from peers, teachers, and institutions. Unmet self-actualization needs were uncommon. Participants felt pride in their medical journey; however, some perceived that their financial struggles hindered them from realizing their full potential.

CONCLUSIONS

Previously reported attrition and adverse academic outcomes among low-income students may be linked to challenges they experience trying to more fully meet important human needs. This finding underscores the need to approach wellness holistically and ensure students do not exist in a prolonged state of unmet needs. Recommendations that accreditation bodies and medical schools could implement to promote tailored support for low-income and other marginalized learners are provided.

Diversity Among EMS Fellows

OBJECTIVES

Emergency medical services (EMS) personnel, including EMS physicians, should reflect the diversity of the patient populations they serve to ensure equitable healthcare outcomes. The historical predominance of White male EMS medical directors may contribute to disparities in patient care. Recruiting and training a diverse cadre of EMS fellows is a key step toward fostering equity in EMS leadership and improving outcomes for diverse communities. This study examines demographic trends among EMS fellows and explores their implications for advancing equity in EMS care delivery.

METHODS

Publicly available data were extracted from the Accreditation Council for Graduate Medical Education (ACGME) Data Resource Books for the academic years 2012-2013 through 2022-2023. Data regarding residents' and fellows' self-identified gender and race/ethnicity were analyzed for EMS fellowships, emergency medicine (EM) residencies, and all residencies/fellowships. The investigation utilized chi-square tests to analyze associations between categorical variables, such as gender and race, and the Cochran-Armitage Trend Test to evaluate trends in proportions across years.

RESULTS

Data for 680 EMS fellows during the 11-year period were reviewed. Overall, 66% (range 55-78%) of EMS fellows were male and 34% (range 22-45%) were female. There was a smaller proportion of female EMS fellows than female EM residents (37%), female toxicology fellows (39%), female pediatric emergency medicine (PEM) fellows (65%), and female residents overall (45%). The majority of EMS fellows identified as White (75%, range 69-100%). The next most commonly reported race/ethnicity by EMS fellows was Asian (8%, range 0-13%). There was a larger proportion of White EMS fellows than White toxicology fellows (68%), White EM residents (60%), White PEM fellows (49%), and White residents overall (45%). There were no significant trends in gender or race/ethnicity of EMS fellows over time.

CONCLUSIONS

Over the first 11 years since fellowship accreditation, one third of EMS fellows were female and more than three quarters of EMS fellows were White. EMS leaders, including fellowship directors, should strengthen the recruitment of women and underrepresented racial and ethnic minority groups in EMS medical direction.

Diversity is essential in cardiovascular medicine and subspecialties: A comprehensive report of gender, racial, and ethnic representation among cardiovascular fellows from 2005 to 2022

INTRODUCTION

The diversity of the healthcare workforce is essential for equitable and effective patient care. This comprehensive report analyzes the representation trends among cardiovascular fellows in the US over an 18-year period, focusing on gender, racial, and ethnic representation.

METHODS

Utilizing data from the National Graduate Medical Education Census, this study analyzes trends in representation across gender, race, and ethnicity among cardiovascular medicine fellows. It examines the expansion of cardiology programs and fellow positions in specialties, assessing the evolution of diversity between 2005 and 2022 using J point trend analysis software.

RESULTS

The analysis highlights a stark gender disparity with women comprising only 22 % of fellows, this percentage is even lower in subspecialties. Racial and ethnic disparities are also evident, with Black and Hispanic cardiologists significantly underrepresented, comprising only 12.8 % of cardiac fellows in 2021, even though these groups form 31.9 % of the U.S.

POPULATION

However, a slow but positive trend toward diversity is noted, with female and Black fellows' representation in cardiology on the rise with AAPC of 5.1 and 3.9, respectively.

CONCLUSION

Our analysis revealed continued racial and gender disparities in the cardiology specialty. This report calls for concerted efforts from academic institutions, healthcare organizations, and policymakers to implement effective strategies for diversity and inclusion, reflecting the aim of creating a workforce that mirrors the diversity of the population it serves.

A qualitative study of micro and macroaggression experienced by Black surgical trainees through an anonymous reporting

INTRODUCTION

This qualitative study explores experiences of bias, discrimination, and mistreatment among Black surgical trainees using an anonymous reporting system implemented across multiple academic surgical programs in the United States.

METHODS

Over six months, Black surgical trainees submitted anonymous reports detailing mistreatment and bias. Thematic analysis was used to identify key patterns, guided by both predefined concepts and emergent themes. The analysis was conducted by multiple team members with backgrounds in surgical education and qualitative research.

RESULTS

Six key themes were identified: microaggressions, abuse of power, professional barriers, identity and visibility, support and advocacy, and impacts on well-being. Trainees reported significant emotional and career-related effects, with many seeking mentorship or support, though institutional responses were often inadequate.

CONCLUSIONS

This study highlights systemic issues within surgical training and underscores the need for targeted interventions to promote equity, safety, and inclusivity in surgical education.

The Impact of Racial/Ethnic Concordance in Patient-Reported Shared Decision-Making and Communication During the COVID-19 Era

BACKGROUND

Patient-provider racial/ethnic concordance may mitigate disparities, which is likely due in part to improved communication. The COVID-19 pandemic exacerbated disparities and raised questions on communication, warranting further exploration to inform equitable care.

OBJECTIVES

This study aimed to investigate the influence of patient-provider racial/ethnic concordance on patient-reported shared decision-making and communication during the early stages of the pandemic.

RESEARCH DESIGN

Stepwise logit models were constructed of short-term non-modifiable factors (race/ethnicity, education, age, marital status), modifiable factors (health insurance, poverty status), and self-reported health status predicting communication outcomes-whether the provider included the patient in decision-making and communicated treatment options.

SUBJECTS

Adults from the 2020 US Medical Expenditure Panel Survey (N=9634), weighted consistent with complex sampling.

MEASURES

Shared decision-making and communication of treatment options by the primary care provider were assessed by patient surveys. Demographic characteristics included race/ethnicity, poverty status, age, marital status, education, and insurance status.

RESULTS

Concordance was associated with greater age and socioeconomic status, and being married, White, and in good health. Concordance was associated with patient-reported shared decision-making and communication of treatment options. The associations between demographic characteristics and communication outcomes differed significantly by concordance status, which further differed by race/ethnicity. For example, shared decision-making was predicted by education for discordant Hispanic patients and marital status for discordant White patients, but neither were predictive among concordant patients.

CONCLUSIONS

The findings suggest a potential association between concordance on shared decision-making and communication dynamics, emphasizing the need for additional research to clarify how similarities and differences may influence health care interactions.

Barriers and Facilitators to Accessing Mental Health Supports Among Black Perinatal Women: Application of the Patient-centered Access Framework

Black perinatal women experience high rates of mental health disorders including depression and traumatic stress disorders, but also face significant disparities in access to mental health treatment. We conducted focus groups with 43 Black perinatal women in the Southeastern U.S. to understand barriers and facilitators that affect their access to mental health services during pregnancy and post-partum as well as recommendations to promote culturally response trauma screening and services. This study leveraged Levesque's patient-centered access framework to inform coding and analysis. Barriers to access and corresponding recommendations were identified among all five dimensions and abilities of the patient-centered access framework. Medical mistrust was a key theme that spanned several dimensions-including the likelihood of seeking care and comfort disclosing mental health concerns to a provider. Study recommendations included the need for provider training on delivering trauma-informed, culturally responsive care, increased transparency about trauma screeners to mitigate patient mistrust, and the establishment of integrative care approaches to reduce time and cost barriers to accessing mental health supports.

County-Level Analysis of the Health Impact of Black Physicians in Georgia

Despite the longstanding underrepresentation of Black physicians in the U.S., greater representation of Black physicians in the physician workforce can positively impact health outcomes. In Georgia, racial and ethnic health inequities are prevalent, and physician workforce shortages are acute. This study aims to assess the impact of Black physician representation on three health outcomes: Years of Potential Life Lost (YPLL) before age 75 and hospital discharges and emergency room visits related to chronic Ambulatory Care Sensitive Conditions (ACSC) or coronavirus disease 2019 (COVID-19). Data sources included a survey administered by the Georgia Composite Medical Board and the Online Analytical Statistical Information System (OASIS) to analyze county-level outcomes for non-Hispanic Black (NHB) and non-Hispanic White (NHW) populations from 2016 to 2019 and 2020 to 2022. We used linear regression models to assess the association between Black physician representativeness in the county physician workforce and NHB-NHW disparities in the outcome measures. We found that counties with higher Black physician representativeness experienced better health outcomes for both NHB and NHW populations, with reduced racial disparities in hospital discharges and YPLL, particularly during the COVID-19 pandemic. The study underscores the importance of increasing Black physician representation in the workforce to advance health equity in Georgia.

Differential attainment in UK postgraduate medical examinations: examining the relationship between sociodemographic differences and examination performance

BACKGROUND

Differential attainment (DA), or differences in performance of groups (rather than individual differences), has been observed in a number of postgraduate medical specialty examinations used in UK medical training. Until now, much of the published research on DA has been limited in scope and size to one specialty, one examination or one type of assessment. This retrospective cohort study addressed this gap by examining the relationship between numerous sociodemographic differences and performance in almost all UK postgraduate medical examinations using a dataset of more than 180,000 examination attempts by UK and international medical graduates, adjusting for prior academic attainment.

METHODS

This retrospective cohort study used the UK Medical Education Database (UKMED) to analyse the impact of a range of sociodemographic factors on performance in all UK postgraduate medical examinations aggregated into written and clinical exams. Pass/fail data at the first examination attempt were analysed for all candidates (UK medical school graduates (UKG) and those from non-UK schools (IMG)) sitting an examination between 2014 and 2020. Univariate analyses identified variables to carry forward into multivariate logistic regression models. Informed by previous research, all models were adjusted for prior academic attainment.

RESULTS

180,890 examination first-attempts were made by UKG and IMG candidates, and 121,745 (67.3%) passed at the first attempt. Multivariate regression models showed that place of primary qualification (UKG vs IMG), gender, age, ethnicity, religion, sexual orientation, disability status and working less than full-time were all statistically significant, independent predictors of examination outcomes for all examination candidates. Additionally, there were significant associations between socioeconomic backgrounds and performance for UKGs alone. The strongest independent predictors of failing written and clinical examinations were graduating from a non-UK medical school, having a minority ethnic background and having a registered disability.

CONCLUSIONS

This, the largest study of UK postgraduate medical examination outcomes, identified sociodemographic differences that were independently predictive of performance in written and clinical postgraduate medical examinations. Further analysis is now required to ascertain whether these group-level differences exist in each postgraduate medical examination, the majority or a select few.

TRIAL REGISTRATION

Not applicable.

Disparities in Utilization Rates of Total Knee and Hip Arthroplasty Among Racially Visible Populations in Canada: A Retrospective Cohort Analysis

BACKGROUND

Published evidence on total hip arthroplasty (THA) and knee arthroplasty (TKA) among racially visible (RV) populations suggests inequities in utilization rates. The study's aim was to compare THA and TKA utilization rates in RV populations to the general population (non-RV). Additionally, we compared rates in populations of African descent (AD) to non-African descent (non-AD) population.

METHODS

The study population was identified from the 2016 Canadian long-form census, and minority status was self-reported. Statistics Canada and Canadian Institute of Health Information used personal information from multiple sources to construct a unique identifier, enabling accurate linkage across data sources. Census data captured key covariates including age, sex, and income. Procedures of THA and TKA were identified from the Discharge Abstract Database and National Ambulatory Care Reporting System. Multivariate logistic regression was employed in comparing utilization rates between groups, controlling for confounders including age, sex, and income. Chi-square statistics were used to test for statistically significant differences at a 95% confidence level.

RESULTS

The observed utilization rates for TKA and THA were lower for RVs and ADs compared to non-RV and non-AD populations, respectively. Multivariate analyses revealed an adjusted odds ratio (OR) of RV individuals undergoing THA of 0.22 (P < 0.001) compared to non-RV individuals, with a lower probability for RVs. Similarly, RV individuals had a statistically lower probability of undergoing TKA compared to non-RV individuals (OR 0.72, P < 0.001). The probability of AD individuals undergoing THA (OR 0.46, P < 0.001) and TKA (OR 0.73, P < 0.0001) after adjusting for confounders was lower compared to non-AD populations.

CONCLUSIONS

Disparities in THA and TKA utilization rates were pervasive among racialized populations across Canada. We advocate that future studies on access to investigate causality or potential factors driving the observed disparity, such as language barriers and sociocultural perceptions regarding surgery.

LEVEL OF EVIDENCE

III.

Gender based disparities in research on injuries in NCAA athletes

OBJECTIVES

Females participate in clinical research at a much lower rate than males, leading to clinical outcome disparities. The objective of this study was to determine whether gender-based disparities exist in orthopedic sports medicine injury research on NCAA college student-athletes.

METHODS

A PubMed search was conducted in September 2023 using the search terms 'NCAA,' 'injury,' and each of the 24 individual NCAA sports between 1980 and 2023. Statistical analysis was performed via determination of adjusted correlation coefficient R2 and multiple linear regression models. Gender was the independent variable, number of studies was the dependent variable.

RESULTS

Of 1,553 studies initially identified, 790 met inclusion criteria and underwent full-text review. Of NCAA studies that assessed injury rates (injury rate studies) and those that evaluated other outcomes such as performance (non-injury rate studies), 468 of 790 (59%) discussed male collegiate athletes and 318 (40%) discussed females. For females, there was a negative association between athlete-exposure rate and injury rate studies (expected decrease of 0.31 studies per 100,000 athlete-exposures) and between athlete-exposure rate and non-injury rate studies (decrease of 0.007). For males, there was a positive association for each (increase of 1.15 and 1.96). Injury rates were positively associated with injury rate study numbers for both males and females (increase of 3.71). There was no significant relationship between injury rates and non-injury rate study numbers for either gender.

CONCLUSION

This study demonstrates gender disparities in orthopedic sports medicine injury research for collegiate athletes. There was a negative association between athlete-exposure rate and injury rate or non-injury rate studies for female NCAA athletes, but a positive association for males.

CLINICAL RELEVANCE

It is important to ensure that sports medicine research is focused on both male and female NCAA athletes to be able to evaluate injuries, outcomes, and opportunities for injury prevention.

A Mixed-Methods Analysis and Personal Narratives of Black Maternal Health Experiences in the American Healthcare System

Purpose The growing disparities and vulnerabilities in healthcare have contributed to alarmingly high maternal mortality rates for Black/African American women. In the United States, the maternal mortality rate is exponentially higher than that of other industrialized nations. Furthermore, within this nation, Black women face a disproportionately greater risk of maternal death. Therefore, blending the knowledge from these realities, it is evident that the immense number of women dying in our industrialized nation, compared to others, are primarily Black women. With knowledge of this devastating disparity, the fundamental objective of this project is to provide a voice for the Black/African American individuals whose lives are claimed prematurely due to systemic health disparities and lack of quality care. Our study aims to learn more intimate and personal recollections of the birthing experiences of Black/African American women as they are currently the most vulnerable. Method From June to December 2023, a mixed-methods study was conducted that included a quantitative questionnaire, which received 60 responses. Fourteen of those participants also took part in the qualitative portion, consisting of four interview groups that provided more insights into their experiences. Results This paper presents the mixed-method findings from both the questionnaire and interview groups, which revealed a spectrum of experiences. The survey results were analyzed and categorized as either sufficient care or insufficient care necessitating improvement. Additionally, participants provided intimate details through written and verbal responses, which have been illuminating. Conclusion Ultimately, prioritizing the voices of Black women through a patient-centered approach to addressing maternal mortality highlights the need for culturally appropriate interventions, enhanced healthcare education, and strengthened advocacy. These efforts are essential in creating a more equitable system that improves maternal health outcomes and reduces racial inequities.

Orthopaedic Consultation is Associated With Fewer Patient-Perceived Barriers to Total Joint Arthroplasty

Background

Orthopaedic consultations' influence on perceived barriers to total joint arthroplasty (TJA) remains unclear. This study explores how orthopedic consultations are associated with patient perceptions of barriers to TJA.

Methods

We performed a post-hoc analysis of questionnaire responses based on data from a previous study that used semi-structured interviews with patients with advanced osteoarthritis. This earlier study identified 5 key barriers to TJA-trust in surgeon, cost/insurance, recovery, surgical outcome, and timing of surgery-and highlighted significant racial differences in these barriers. Our analysis focused specifically on the role of orthopaedic consultations. Using multiple logistic regression models, we compared responses from patients who had an orthopaedic consultation to those who did not, while adjusting for race, age, Hip Disability and Osteoarthritis Outcome Score, Joint Replacement/Knee Injury and Osteoarthritis Outcome Score, Joint Replacement, insurance status, education level, and prior discussions about TJA.

Results

Of the 696 participants, 88% were female, 77% White, 11% Black, and 9% Hispanic. Nearly half (49%) had an orthopaedic consultation. Participants who had consulted with an orthopaedist were older, more likely to be college graduates, Medicare beneficiaries, have consulted a primary care physician, attempted conservative management including joint injections, braces, and physical therapy. After adjusting for participant factors, orthopaedic consultation was a predictor of fewer perceived cost/insurance and timing barriers. However, no differences were observed in other barriers.

Conclusions

Orthopaedic consultation is associated with fewer reported cost/insurance and timing barriers to TJA. Addressing barriers of concern to patients in the context of orthopaedic consultations could further improve TJA utilization.

Evaluation of Clinically Integrated Community Health Worker Support Interventions for Adults With Cardiovascular Disease: A Literature Review Guided by the PRISM Framework

BACKGROUND AND PURPOSE

Chronically ill individuals with cardiovascular diseases (CVDs) have been extensively challenged by the complexities of disease management. Although clinically integrated community health worker (cCHW) support interventions have been increasingly implemented to help manage CVDs, a comprehensive analysis of interventions implemented in real-world settings is lacking. Additionally, the influence of contextual factors (eg, patient/organization characteristics) on such interventions is underexplored. Guided by the PRISM framework, the purpose of this review is to understand cCHW interventions supporting individuals with CVDs in the clinical settings.

METHODS

PubMed, CINAHL and APA PsycInfo databases were searched using the following primary keywords: (community health worker), (integrat*), (chronic) and (cardiovascular disease). Studies investigating the integration of CHWs in the care of adults with CVD published from inception to 2023 were included.

RESULTS

A total of 25 studies were included in the review. Majority of studies (n = 23) measured intervention effectiveness and often positively impacted outcomes, including blood pressure and chronic disease control. Compared to effectiveness, the rest of the RE-AIM domains were underexplored.

CONCLUSION AND IMPLICATIONS

cCHW programs have demonstrated some evidence in improving health outcomes in individuals with CVD. However, less is known about their impact on other relevant multidimensional RE-AIM outcomes.

Physician Workforce Diversity Is Still Necessary and Achievable if It Is Intentionally Prioritized

The 2023 Supreme Court Decision from Students for Fair Admissions v. Harvard and Students for Fair Admissions v. University of North Carolina threatens the current progress in achieving diversity within undergraduate and graduate medical education. This is necessary to achieve a diverse healthcare workforce, which is a key to healing historical healthcare trauma, eliminating health disparities, and providing equitable healthcare access for all communities. Although the Supreme Court decision seems obstructionist, viable opportunities exist to enhance recruitment further and solidify diversity efforts in undergraduate and graduate medical education to achieve these goals.

Effects of Implicit Racial Bias and Standardized Patient Race on Genetic Counseling Students' Patient-Centered Communication

Clinician racial bias has been associated with less patient-centered communication, but little is known about how it affects trainees' communication. We investigated genetic counseling students' communication during sessions with Black or White standardized patients (SPs) and the extent to which communication was associated with SP race or student scores on the Race Implicit Association Test (IAT). Sixty students conducted a baseline SP session and up to two follow-up sessions. Students were randomly assigned to a different White or Black SP and one of three clinical scenarios for each session. Fifty-six students completed the IAT. Session recordings were coded using the Roter Interaction Analysis System. Linear regression models assessed the effects of IAT score and SP race on a variety of patient-centered communication indicators. Random intercept models assessed the within-student effects of SP race on communication outcomes during the baseline session and in follow-up sessions (n = 138). Students were predominantly White (71%). Forty students (71%) had IAT scores indicating some degree of pro-White implicit preference. Baseline sessions with White relative to Black SPs had higher patient-centeredness scores. Within-participant analyses indicate that students used a higher proportion of back-channels (a facilitative behavior that cues interest and encouragement) and conducted longer sessions with White relative to Black SPs. Students' stronger pro-White IAT scores were associated with using fewer other facilitative statements during sessions with White relative to Black SPs. Different patterns of communication associated with SP race and student IAT scores were found for students than those found in prior studies with experienced clinicians.

Outcomes of major cardiac operations are not improved for black patients at black-serving institutions

Objective

Although provider-patient racial concordance has been associated with improved outcomes among patients of Black race, it is unclear if increased representation at the institutional level is associated with the same benefits.

Methods

Adults undergoing coronary artery bypass grafting and valve operations were tabulated from the 2016-2020 National Inpatient Sample. Black-serving quartiles were generated using the annual proportion of Black patients admitted for all diagnoses. The primary end point was in-hospital mortality with Society of Thoracic Surgeons-defined major complications, postoperative length of stay, and costs as secondary outcomes. Mixed regression models were used to ascertain the association between Black-serving quartile designation and outcomes of interest; an interaction term was used to evaluate the incremental association of race and Black-serving quartiles.

Results

Of an estimated 1,203,120 patients, 7.2% were Black. After adjustment, highest Black-serving quartile hospitals demonstrated higher odds of mortality (adjusted odds ratio, 1.18, 95% CI, 1.06-1.30) and major complications (adjusted odds ratio, 1.19, 95% CI, 1.11-1.28) compared with lowest Black-serving quartile hospitals. Notably, Black patients had significantly higher mortality compared with non-Black patients at highest Black-serving quartile institutions (3.3%, 95% CI, 3.0-3.7 vs 2.6, 95% CI, 2.4-2.8), but not at the lowest (3.1%, 95% CI, 1.8-4.4 vs 2.2, 95% CI, 2.1-2.4). Black patients exhibited a stepwise increase in risk of major complication rates, postoperative length of stay, and costs with higher Black-serving quartiles.

Conclusions

Highest Black-serving quartile hospitals had worse clinical outcomes overall compared with those in the lowest Black-serving quartile. Unfortunately, Black patients had additional increased mortality, complications, postoperative length of stay, and costs at high Black-serving quartile institutions, highlighting the compounding effects of patient and hospital-level racial disparities.

Examining racial, ethnic, and gender representation of applicants and matriculants to emergency medicine residency programs from 2005 to 2021

Objectives

The emergency medicine (EM) patient population is racially and ethnically diverse, and the presence of racial and gender minority physicians may help overcome health disparities among these patients. The purpose of this study was to examine representation and its trends of racial, ethnic, and gender identities entering the EM workforce.

Methods

Reports on race, ethnicity, and gender for medical school graduates, EM applicants, and residents were obtained for the years 2005-2021. Racial and ethnic groups included Asian, Black, Hispanic, and White; gender identities included men and women. The proportion of each identity in each cohort was divided by a denominator of their corresponding U.S. medical school graduate proportion, producing representation quotients among applicants and matriculants (RQapp, RQmat) that refer to the group's medical school graduate representation. Mann-Whitney U-tests were used on RQ averages to assess for differences in representation among applicants compared to matriculants. Linear regressions of yearly RQs were used to assess representation trends.

Results

Men who self-identified as Black (RQapp 1.50), Hispanic (RQapp 1.84), or White (RQapp 1.15) had the highest EM applicant representation trend relative to other groups while making up 3.5%, 5.4%, and 36.3% of all applicants, respectively. Asian women were the least represented group among applicants (RQapp 0.52), dropping from 10.7% of medical school graduates to 5.7% of EM residency applicants. Among EM matriculants, Hispanic men (RQmat 1.56) and White men (RQmat 1.43) were the only overrepresented groups. Linear regression indicated that nearly all groups had significant increases in applicant representation over time, except for Asian women and Black men. White men and White women were the only two groups to experience increases in matriculant representation compared to their applicant counterparts.

Conclusions

Asian men, Asian women, and Black women remain underrepresented in EM residencies. Additional recruitment efforts to ensure their equitable representation are necessary in future application cycles.

Genomic sequencing in diverse and underserved pediatric populations: Parent perspectives on understanding, uncertainty, psychosocial impact, and personal utility of results

PURPOSE

Limited evidence evaluates parents' perceptions of their child's clinical genome-scale sequencing (GS) results, particularly among individuals from medically underserved groups. Five Clinical Sequencing Evidence-Generating Research consortium studies performed GS in children with suspected genetic conditions with high proportions of individuals from underserved groups to address this evidence gap.

METHODS

Parents completed surveys of perceived understanding, personal utility, and test-related distress after GS result disclosure. We assessed outcomes' associations with child- and parent-related factors: child age; type of GS finding; and parent health literacy, numeracy, and education.

RESULTS

A total of 1763 parents completed surveys; 83% met "underserved" criteria based on race, ethnicity, and risk factors for barriers to access. We observed high perceived understanding and personal utility and low test-related distress. Outcomes were associated with the type of GS finding; parents of children with a pathogenic or likely pathogenic finding endorsed higher personal utility and more test-related distress than those whose children had a variant of uncertain significance or normal finding. Personal utility was higher in parents who met the criteria for "underserved."

CONCLUSION

Our findings shed light on correlates of parents' cognitive and emotional responses to their child's GS findings and emphasize the need for tailored support in disclosure discussions.

Advancing opportunity and representation in the American Venous Forum

OBJECTIVE

Diversity, equity, and inclusion (DEI) within the physician workforce is critical to establishing a diverse provider network that accurately represents the patient population served by vascular surgeons. Vascular surgery remains a largely male-dominated surgical specialty, and the number of women in leadership positions in academic surgical specialties continues to be disproportionate. The representation of women in leadership roles differs across vascular surgery societies. The goal of this study is to provide an update on the representation of women and incorporation of DEI topics at American Venous Forum (AVF) annual meetings and across committees.

METHODS

A retrospective review was conducted of available scientific meeting programs and abstracts presented at the AVF from 2010 to 2023. The time period was divided into before 2019 and after 2019, as this was the year that the Society for Vascular Surgery established the Task Force on DEI. Women's participation and DEI domains were documented for each year. A two-sample unpaired t-test was used to compare mean percentages.

RESULTS

Specifically, within the AVF, women's representation across all roles (presenters, senior authors, moderators, committee chairs, committee members, and officers) has increased when comparing prior years (2010-2019) with a more recent time period (2020-2023). The largest increase was observed for moderators (12.6% vs 30.2%; +17.6%), and the smallest increase was observed for presenters (21.1% vs 28.9%; +7.8%). When comparing the same time periods, the mean percentage of DEI domains (access to care, race and ethnicity, gender, age, health literacy, and socioeconomic status) highlighted in research presentations at AVF annual meetings has increased numerically over time but is not statistically significant except for the DEI domain of age (1.34% vs 3.28%; P = .0008).

CONCLUSIONS

Although there have been positive improvements in the proportion of women in leadership roles at the AVF, the integration of DEI domains at AVF annual meetings continues to show slow progress. This study reflects an opportunity for AVF leaders and councils to prioritize strategies to incorporate important DEI domains into our annual meetings and mission-related efforts. Intentional progress in these areas will ultimately contribute to more successfully carrying out the AVF Core Values (VEINS: Values and integrity, Education, Inclusivity, equity, diversity, Nurturing, Scientific excellence and research).

Native American Representation and Diversity Initiatives Within Orthopaedic Surgery: An Update and Road Map to Success

Orthopaedic surgery lags behind other specialties in terms of diversity. This lack of representation is especially evident within the Native American population. Native American/Alaskan Natives represent approximately 2.9% of the overall US population but comprise just 0.4% of orthopaedic surgeons within the United States. Currently, no Native American-specific orthopaedic inclusion or recruitment programs exist. There are a multitude of programs that exist to recruit Native American applicants into health care. These include pipeline programs and scholarships from the Indian Health Service (IHS), mentorship programs from a multitude of Native American medical societies, and IHS recruitment programs targeted at Native American preferential hiring. Dozens of grants and national diversification programs that are not specific to Native Americans are also available. Programs such as the AAOS IDEA Grant, Nth Dimensions, and The Perry Initiative have been successful in diversifying the orthopaedic surgery pipeline. This review highlights the paucity of Native American representation within orthopaedics and identifies current programs and resources for Native Americans. This article serves as a guide for Native Americans pursuing a career in orthopaedic surgery, as well as inspiration for future programs directed at increasing Native American representation.

Comparing In-Person, Telephonic, and Video-Based Treatment of Depression in Adult Primary Care During the COVID-19 Pandemic

INTRODUCTION

The COVID-19 pandemic forced a rapid shift toward virtual modalities for the treatment of depression in primary care.

METHODS

Participants were adults 18 years and older with a new episode of depression diagnosed in primary care between March 1, 2020, and May 21, 2021, and moderate-to-severe symptoms of depression at the time of diagnosis (N = 9619). Outcomes were 1) antidepressant medications prescribed and dispensed (referred to as received), as well as adherence to those medications; 2) referrals made to depression-related services and the receipt of those services; and 3) a follow-up visit completed with the diagnosing practitioner regardless of treatment actions.

RESULTS

Patients were 42.4 ± 17.8 years old, and 77.6% had moderate-to-severe symptoms at diagnosis. Most patients were women (70.4%), 48.2% were Hispanic, and 8.4% were Black. Telephone visits were associated with 64% increased odds of having an antidepressant prescribed when compared to in-person visits. However, patients prescribed an antidepressant during a telephone visit were 52% less likely to receive this prescription when compared to patients who were prescribed an antidepressant during an in-person visit. Telephone and video visits were associated with 48% and 37% decreased odds, respectively, of having a follow-up visit with the prescribing practitioner when compared to an in-person visit.

CONCLUSION

Telemedicine for depression in adult primary care may result in greater antidepressant prescribing than in-person care, but these medications are less likely to be received. This study's findings suggest that health systems should adjust electronic decision support tools (such as mail-order pharmacies) to ensure virtual care decisions are implemented.

Diversity, Equity, and Inclusion Content on Internal Medicine Fellowship Programs' Webpages

BACKGROUND

One way in which graduate medical programs can attract a diverse applicant pool is through the utilization of their program's website to display their diversity, equity, and inclusion initiatives to prospective trainees. Given that internal medicine subspecialists makeup a significant percentage of our country's practicing physicians, a diverse physician workforce within these fields of medicine is imperative.

OBJECTIVE

The purpose of this study is to evaluate the prevalence and type of DEI content on prominent internal medicine subspecialty fellowship webpages.

METHODS

One thousand five hundred twenty-three fellowship programs' websites were analyzed utilizing a standardized scoring system for five separate DEI criteria across nine internal medicine subspecialities during October 2023. Programs were evaluated for the presence of the following criteria: (1) fellowship-associated DEI webpage, (2) DEI commitment statement, (3) DEI initiatives (summer research opportunities for URiM individuals, DEI council, etc.), (4) link to the institution's DEI homepage, and (5) information about bias training.

RESULTS

Of the 1523 program websites analyzed, 57.3% had no DEI content on their webpages. Of those that did, a link to the institution's DEI homepage was the most prevalent factor (35.3). On average, endocrinology fellowship program websites had the most DEI content, whereas gastroenterology fellowship program websites had the least.

CONCLUSION

The results of this study demonstrate an overwhelming lack of DEI content across all internal medicine subspecialty training programs' webpages. These findings are relevant to fellowship program leadership as they represent an actionable area of improvement within the realm of DEI to improve representation among different groups at training programs.

Racial Disparities in Doctor-Patient Communication: Examining Doctors' Encounters with Black and White Patients

Healthcare disparities persist in the USA, with Black patients often receiving lower-quality care. Effective doctor-patient communication is crucial for influencing satisfaction, adherence to treatment, and overall health outcomes. This study examined racial disparities in doctor-patient communication, focusing on encounters with Black and White patients recently diagnosed with myelodysplastic neoplasm (MDS). Thirty-seven oncologists participated in simulated encounters with trained actors portraying either Black or White patients. Using an innovative approach combining the comparison of communication characteristics, thematic content, and linguistic analyses, we observed significant disparities in time allocation, linguistic complexity, and relation-building efforts. Encounters with Black patients were notably shorter, with doctors using fewer words per sentence, asking fewer questions, and employing less inclusive and optimistic language. Doctors also had less thorough discussions about transplant options and used fewer words communicating authenticity when talking with Black patients. The post-encounter surveys revealed that doctors were not aware of their shortcomings when interacting with Black patients. The findings provide important insights for the development of training programs aimed at improving healthcare outcomes for marginalized communities and reducing racial healthcare disparities.