Implicit bias toward cervical cancer: Provider and training differences

Suicide rates of cervical cancer patients in the United States - Who is most at risk? A retrospective study of 69,493 patients

OBJECTIVE

This study aims to identify demographic and treatment factors associated with suicide risk among cervical cancer patients in the United States.

METHODS

Data were obtained from the SEER database (2000-2020). Women with cervical cancer and follow-up time were included. Demographics and treatment history for women who died by suicide were compared to those who did not using chi-square tests. Suicide rates were compared to age-matched U.S. WHO 2019 data with the Mantel-Haenszel test. Univariate logistic regression estimated odds ratios for suicide risk, and Kaplan-Meier survival analysis examined overall survival (excluding suicide) by demographic and treatment factors. Linear regression assessed the link between time from diagnosis to treatment and time from diagnosis to suicide.

RESULTS

Among 69,493 cervical cancer patients diagnosed from 2000 to 2020, most were White (75.9 %), aged 30-49 (46.4 %), lower-middle income (52.0 %), from metropolitan counties (88.0 %), and had localized disease (35.0 %). Fifty-eight patients died by suicide, with a suicide risk 8.8 times higher than the general population. Younger age groups (15-29 and 30-49) had the highest risk, being 18.9 and 11.2 times more likely to die by suicide, respectively. Suicide risk was significantly associated with age, ethnicity, stage, year of diagnosis, and chemotherapy, with highest risk in younger, Non-Hispanic, localized stage, diagnosed from 2000 to 2005, and no chemotherapy (p < 0.05). Delayed treatment correlated with shorter time from diagnosis to suicide (R² = 0.124; p = 0.015).

CONCLUSIONS

Suicide rates are significantly elevated among cervical cancer patients, especially in young, Non-Hispanic patients with localized disease and no chemotherapy. Delayed treatment was linked to shorter time to suicide, emphasizing the need for targeted mental health support.

Empathic Communication and Implicit Bias in the Context of Cancer Among a Medical Student Sample

Oncology clinicians often miss opportunities to communicate empathy to patients. The current study examined the relationship between implicit bias (based on cancer type and ethnicity) and medical students' empathic communication in encounters with standardized patients who presented as Hispanic (lung or colorectal) individuals diagnosed with cancer. Participants (101 medical students) completed the Implicit Association Test (IAT) to measure implicit bias based on cancer type (lung v. colorectal) and ethnicity (Hispanic v. non-Hispanic White). Empathic opportunities and responses (assessed by the Empathic Communication Coding System; ECCS) were evaluated in a mock consultation (Objective Structured Clinical Examination; OSCE) focused on smoking cessation in the context of cancer. Among the 241 empathic opportunities identified across the 101 encounters (M = 2.4), 158 (65.6%) received high empathy responses from the medical students. High empathy responses were most frequently used during challenge (73.2%) and emotion (77.3%) opportunities compared to progress (45.9%) opportunities. Higher levels of implicit bias against Hispanics predicted lower odds of an empathic response from the medical student (OR = 3.24, p = .04, 95% CI = 0.09-0.95). Further work is needed to understand the relationship between implicit bias and empathic communication and inform the development of interventions.

Rehearsing empathy: exploring the role of poetry in supporting learning

Empathy is an important aspect of therapeutic relationships in health and social care settings. Health educators can foster empathy development in learners through creative writing activities. Drawing on the humanities, specifically poetry, this paper offers strategies for educators to support empathy development in learners, with a focus on service user poetry and associated creative writing activities. We discuss how poetry can enable alternative perspectives about care to emerge thereby challenging previously held assumptions about mental and physical states. Using poetry can enable a rehearsal of empathy by bringing experiences to the learner in a safe and facilitated environment. Through creative writing activities, we believe that students can learn to better understand and empathise with others, as well as explore their own feelings and experiences related to caregiving, to support self-care.

Understanding racial disparities in health care expenditures for cervical cancer

BACKGROUND

Cervical cancer demonstrates a notable efficacy in treatment, evidenced by a 92% 5-year survival rate among cases diagnosed at a localized stage. In 2020, the estimated annual national expenditure for cervical cancer care amounted to $2.3 billion in the United States. Limited real-world data are available for racial disparities in health care expenditures for cervical cancer.

OBJECTIVE

To evaluate racial disparities associated with annual health care expenditures among patients diagnosed with cervical cancer in the United States.

METHODS

A retrospective observational cohort study of annual health care expenditures in patients with cervical cancer diagnosed during 2014-2019 was performed using the Medical Expenditure Panel Survey data. In addition to the descriptive weighted analysis, an unadjusted analysis of the annual health care expenditure was conducted. An adjusted linear regression model with log transformation of the outcome variable was used to evaluate the total annual health care expenditure as well as expenditures by category across the racial groups.

RESULTS

Overall, 826 patients with cervical cancer were identified from the Medical Expenditure Panel Survey during 2014-2019. The majority were classified as White patients (81.2%) and in the age group of 45-64 years (44.65%). On average, the total annual health care expenditure was $11,537 (95% CI = $9,887-$13,186) among the White cohort, $10,659 (95% CI = $6,704-$14,614) among the African American cohort, and $8,726 (95% CI = $6,113-$11,340) among the Hispanic cohort. After adjusting for covariates, the average total annual health care expenditure for the Hispanic cohort was 35% of the total health care expenditure of the White cohort (P < 0.001) and 46% of the African American cohort's health care expenditure (P = 0.02). Specifically, adjusted costs of office-based and outpatient visits for the Hispanic cohort were 47% (P = 0.009) and 57% (P = 0.005) lower than for the White cohort, respectively. The total annual home health care expenditure for the African American cohort was 49% lower than White patients (P = 0.03), and the Hispanic cohort's total expenditure, excluding prescription medicines, was 57% lower than African American patients (P = 0.02).

CONCLUSIONS

This study provides valuable information regarding the health care disparities that need to be addressed among certain minority races. Reducing the disparities in health care spending across racial groups should be included as a crucial element in tackling well-established health care inequities.

Provider Implicit Bias in Prescribing HIV Pre-exposure Prophylaxis (PrEP) to People Who Inject Drugs

BACKGROUND

Multiple HIV outbreaks among people who inject drugs (PWIDs) have occurred in the USA since 2015, highlighting the need for additional HIV prevention tools. Despite high levels of need, pre-exposure prophylaxis (PrEP) is drastically underutilized among PWIDs. Implicit bias toward PWID held by clinicians may impede PrEP scale-up among these underserved patients. This study examined how primary care providers' (PCPs) clinical decisions related to PrEP can be impacted by biases when the patient has a history of substance use.

METHODS

We conducted an online survey of PCPs (n = 208). The survey included the implicit association test (IAT) to assess unconscious attitudes toward PWIDs, direct questions regarding clinicians' explicit PWID attitudes, and an embedded experiment in which we systematically varied the risk behavior of a hypothetical patient and asked PCPs to make clinical judgments.

RESULTS

A minority (32%) of PCPs reported explicit PWID bias. The IAT indicated strong implicit PWID bias (meant IAT score = 0.59, p < .0001) among 88% of the sample. Only 9% of PCPs had no implicit or explicit PWID bias. PWID patients were judged as less likely to adhere to a PrEP regimen, less responsible, and less HIV safety conscious than heterosexual or gay male patients. Anticipated lack of adherence mediated PCPs' intent to prescribe PrEP to PWID.

CONCLUSIONS

PCPs' bias may contribute to PrEP being under-prescribed to PWID. Implicit and explicit PWID biases were common in our sample. This study illustrates the need to develop and test tailored interventions to decrease biases against PWID in primary care settings.

Unconscious Bias among Health Professionals: A Scoping Review

BACKGROUND

Unconscious biases are one of the causes of health disparities. Health professionals have prejudices against patients due to their race, gender, or other factors without their conscious knowledge. This review aimed to provide an overview of research on unconscious bias among health professionals and to investigate the biases that exist in different regions of the world, the health professions that are considered, and the research gaps that still exist.

METHODS

We conducted a scoping review by systematically searching PubMed/MEDLINE, CINAHL, PsycINFO, PsycARTICLES, and AMED. All records were double-screened and included if they were published between 2011 and 2021.

RESULTS

A total of 5186 records were found. After removing duplicates (n = 300), screening titles and abstracts (n = 4210), and full-text screening (n = 695), 87 articles from 81 studies remained. Studies originated from North America (n = 60), Europe (n = 13), and the rest of the world (n = 6), and two studies were of global scope. Racial bias was investigated most frequently (n = 46), followed by gender bias (n = 11), weight bias (n = 10), socio-economic status bias (n = 9), and mental illness bias (n = 7). Most of the studies were conducted by physicians (n = 51) and nurses (n = 20). Other health care professionals were rarely included in these studies.

CONCLUSIONS

Most studies show that health professionals have an implicit bias. Racial biases among physicians and nurses in the USA are well confirmed. Research is missing on other biases from other regions and other health professions.

The State of the Science of Nurses' Implicit Bias: A Call to Go Beyond the Face of the Other and Revisit the Ethics of Belonging and Power

This article summarizes the current state of nurses' implicit bias and discusses the phenomenon from Levinas' face of the Other and ethics of belonging, Watson's human caring and unitary caring science, and Chinn's peace and power theory. Nurses' implicit bias is a global issue; the primary sources of nurses' implicit bias include race/ethnicity, sexuality, health conditions, age, mental health status, and substance use disorders. The current research stays at the descriptive level and addresses implicit bias at the individual level. This article invites nurses to go beyond "the face of the Other" and revisit the ethics of belonging and power.

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

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

"It's Always among Us. I Can't Act Like It's Not.": Women College Students' Perceptions of Physicians' Implicit Bias

Physicians have an opportunity to provide accurate and timely information about sexual behavior to individuals in their care. However, many young people, and in particular college women, are reticent to talk to their physicians about sexual behavior. One explanation for this reticence may be the fact that physicians' implicit bias has the potential to denigrate communication between physicians and patients. However, little is known about how patients perceive physicians' implicit bias, or to what extent it shapes a patient's beliefs about communicating with their physician. Qualitative analysis of in-depth, semi-structured interviews was used to describe and explain the way women college students perceive issues concerning physicians' implicit bias. Results were interpreted through the lens of Communication Privacy Management theory and revealed that participants either avoided or limited communication with a physician as a result of anticipating implicit bias. Major themes included "untangling identity and the effects of physicians' implicit bias" and "seeking to understand physicians' cognition and emotion." These findings have the potential to improve communication interventions both for women college students and healthcare professionals by introducing evidence of patients' perceptions of implicit biases along the intersection of race, young age, sexuality, and female gender in physician-patient communication about sexual behavior.

Physicians perceive that ostomates have decreased quality of life but not overall health: An international survey of physicians

AIM

The aim of this work was to evaluate physicians' perceptions of ostomates' quality of life (QoL) and comfort of care among an international sample of physicians caring for ostomates.

METHOD

This was a cross-sectional survey study. We conducted a survey of primary care physicians (PCP), gastroenterologists (GI), and general surgeons (GS) from three continents using the SERMO online physician platform. We piloted the survey for content, clarity and domain development using a pilot sample of physicians from each speciality before use. We summarized responses to questions related to physician comfort of ostomate care with descriptive statistics. We conducted multiple logistic regression with the primary outcome of physician perception of ostomate QoL.

RESULTS

A total of 617 physicians (PCP 264, GI 176, GS 177) completed the survey representing North America, Europe and Australia similarly. The average age was 46 years and 21% were women. Ninety per cent of physicians care for an ostomate at least once per month. Eighty eight per cent had access to enterostomal nurses. Eighty two per cent of physicians believed that ostomates have decreased QoL. Forty seven per cent believed that ostomates have decreased overall health. Almost half of respondents answered incorrectly to a 'bogus question' citing fake clinical evidence supporting a negative impact of ostomies on social relationships. Increased physician comfort in ostomy care (OR 1.30, p = 0.04) and US-based physicians (OR 1.75, p = 0.01) were associated with increased odds of answering that ostomates have no decreased QoL.

CONCLUSION

Among a diverse international sample, most physicians believe that ostomates have decreased QoL but not overall health. Physician implicit bias, physician comfort and geographical variability account for these findings. Targeted efforts to increase physician comfort in ostomate care and establish universal best practices is needed.

Disparities in gynecologic cancer incidence, treatment, and survival: a narrative review of outcomes among black and white women in the United States

For patients diagnosed with ovarian, uterine, or cervical cancer, race impacts expected outcome, with black women suffering worse survival than white women for all three malignancies. Moreover, outcomes for black women have largely worsened since the 1970s. In this narrative review, we first provide an updated summary of the incidence and survival of ovarian, uterine, and cervical cancer, with attention paid to differences between white and black patients. We then offer a theoretical framework detailing how racial disparities in outcomes for each of the gynecologic malignancies can be explained as the sum result of smaller white-black differences in experience of preventive strategies, implementation of screening efforts, early detection of symptomatic disease, and appropriate treatment. Much research has been published regarding racial disparities in each of these domains, and with this review, we seek to curate the relevant literature and present an updated understanding of disparities between black and white women with gynecologic malignancies.

Leveraging Digital Technology to Reduce Cancer Care Inequities

The rise of digital technologies such as telehealth, mobile apps, electronic medical records, and telementoring for rural primary care providers could provide opportunities for improving equity in cancer care delivery and outcomes. Benefitting from new technologies requires access to broadband internet, appropriate devices (smartphones, computers, etc.) along with basic digital literacy skills to use the devices. When these requirements are not met, the likelihood of widening existing inequities in access to care increases. This article introduces opportunities for improving cancer care using health informatics systems for engaging patients and flagging bias and existing videoconferencing technology to build workforce capacity. Policy recommendations for expanding evidence-based interventions are also highlighted, with the aim of mitigating the effects of workforce shortages and reducing persistent inequities in access to and quality of care.

Improving Health Equity: The Role of the Oncology Advanced Practitioner in Managing Implicit Bias

Implicit bias (IB) is the involuntary activation of thoughts, feelings, attitudes, or stereotypes that exist outside of conscious awareness. Implicit bias develops early in life and research documents the existence of IB across health-care settings. Negative IB impacts patient-provider interactions, produces inferior patient outcomes, and contributes to health-care disparities. Oncology APs are subject to IB and should be aware of its potential impact on professional practice. This manuscript explores the concept of IB and reviews evidence examining the clinical impact of IB in the oncology setting. Strategies for identifying and mitigating IB are explored. Highlights include the use of the Implicit Association Test and emotional intelligence. Advanced practice implications are discussed and range from self-improvement to organizational transformation.

Implicit biases in healthcare: implications and future directions for gynecologic oncology

Health disparities have been found among patients with gynecologic cancers, with the greatest differences arising among groups based on racial, ethnic, and socioeconomic factors. Although there may be multiple social barriers that can influence health disparities, another potential influence may stem from healthcare system factors that unconsciously perpetuate bias toward patients who are racially and socioeconomically disadvantaged. More recent research suggested that providers hold these implicit biases (automatic and unconscious attitudes) for stigmatized populations with cancer, with emerging evidence for patients with gynecologic cancer. These implicit biases may guide providers' communication and medical judgments, which, in turn, may influence the patient's satisfaction with and trust in the provider. This narrative review consolidated the current research on implicit bias in healthcare, with a specific emphasis on oncology professionals, and identified future areas of research for examining and changing implicit biases in the field of gynecologic oncology.

Mitigating Implicit Bias in Radiation Oncology

Implicit bias is one of the most insidious and least recognizable mechanisms that can cause inequity and disparities. There is increasing evidence that both implicit and explicit biases have a negative effect on patient outcomes and patient-physician relationships. Given the impact of Implicit bias, a joint session between ASTROs Committee on Health Equity, Diversity, and Inclusion and the National Cancer Institute (the ASTRO-National Cancer Institute Diversity Symposium) was held during the American Society of Radiation Oncology (ASTRO) 2020 Annual Meeting, to address the effect of implicit bias in radiation oncology through real life and synthesized hypothetical scenario discussions. Given the value of this session to the radiation oncology community, the scenarios and discussion are summarized in this manuscript. Our goal is to heighten awareness of the multiple settings in which implicit bias can occur as well as discuss resources to address bias.

Changing Obstetrics and Gynecology Residency Education to Combat Reproductive Injustice: A Call to Action

Although reproductive injustices and reproductive health disparities are well-documented in the United States, recent studies have begun to explore the health care professional's role in their perpetuation. We hypothesized that obstetrics and gynecology residents would observe reproductive injustices during their training. Thus, using a national survey, we asked obstetrics and gynecology residents to share clinical cases in which discrimination, bias, inequity, or injustice was involved in a patient's reproductive health care and queried their preparedness to respond. Through qualitative analysis, we found that respondents shared cases involving racism, discrimination, and structural barriers to care and that they felt poorly equipped to handle injustice. We call for clinician educators to combat reproductive injustice through three key changes to obstetrics and gynecology residency training: 1) incorporate reproductive justice training into formal residency education; 2) create safe spaces for residents to collectively debrief about their experiences with injustice and collaborate on care improvement; and 3) teach community engagement and advocacy skills that identify, center, and elevate local reproductive health priorities.

What is the Image of the "Typical Cancer Patient"? The View of Physicians

Former research has identified stigmatizing attitudes toward cancer patients in the general population. Little is known about (implicit) attitudes of physicians toward cancer patients. By using the prototype approach, the study investigated German physicians’ prototypical perceptions of cancer patients. Five hundred nineteen physicians (mean age: 46 years, 47% female) who regularly treat cancer patients participated in the questionnaire study. Participants were asked to state three prototype attributes that describe the “typical cancer patient.” Open format answers were coded on the dimensions favorability (coded with unfavorable, favorable, or neutral) and gender-stereotypicality (coded with masculine stereotypical, feminine stereotypical, or gender-neutral). Of all prototype attributes (N = 1,589), 69.9% were coded as unfavorable and 14.3% as favorable, the remaining attributes were neutral (15.9%). Analysis of gender-stereotypicality revealed that nearly half of the attributes (49.5%) were compatible with the feminine, whereas only 6.5% were compatible with the masculine stereotype. The remaining attributes (44.0%) were gender-neutral. There were no significant associations between prototype favorability or gender-stereotypicality and demographic/professional characteristics of physicians. The prototype approach was successful to identify (implicit) attitudes toward cancer patients and might be more sensitive than social distance scales when investigating stigmatizing attitudes. Physicians described the “typical cancer patient” with predominantly unfavorable and feminine attributes, while favorable attributes were underrepresented and positive masculine attributes were barely mentioned. The finding that the “typical cancer patient” lacks (positive) masculine attributes should be followed up in further research.

Health Care Providers' Negative Implicit Attitudes and Stereotypes of American Indians

Research suggests that implicit biases held by health care providers may play a role in perpetuating health disparities. However, minimal work has examined the presence of providers' negative implicit attitudes and stereotypes of American Indians. The current work examined implicit attitudes and stereotypes toward American Indians among 111 health care providers using the Implicit Association Test. Results revealed evidence of negative implicit attitudes toward American Indians. In addition, results showed that providers implicitly stereotype American Indians as noncompliant. This effect was moderated by self-reports of cultural competency and implicit bias training experience such that those reporting cultural competency or implicit bias training reported lower implicit stereotyping than those reporting no cultural competency or implicit bias training. Moreover, medical students reported lower implicit stereotyping than medical residents and practicing physicians. Implications of providers' implicit biases on treatment of American Indian patients and implicit bias reduction research are discussed.

Differences in cervical cancer screening and follow-up for black and white women in the United States

OBJECTIVE

To study differences in screening adherence and follow-up after an abnormal Pap test in Non-Hispanic Black (Black) and Non-Hispanic White (White) women.

METHODS

An observational cohort study using 2010 National Health Interview Survey cancer module to examine HPV knowledge, screening behavior, and follow-up to abnormal Pap test in Black and White women 18 years of age or older without a hysterectomy. We fit logistic regression models to examine associations between race and primary outcome variables including: HPV awareness, Pap test in the last three years, provider recommended Pap test, received Pap test results, had an abnormal Pap test, recommended follow-up, and adhered to the recommendation for follow-up.

RESULTS

Analyzing data for 7509 women, Black women had lower odds ratios [OR] for: 1) HPV awareness (71% vs 83%; OR = 0.42; 95% CI = 0.36-0.49); 2) reporting Pap screening was recommended (59% vs 64%; OR = 0.76; 95% CI = 0.66-0.88), and 3) acknowledging receipt of Pap results (92% vs 94%; OR = 0.64; 95% CI = 0.49-0.83). Group differences persisted after covariates adjustment. In adjusted models, Black women had higher odds of reporting recent Pap screening (84% vs 77%; OR = 1.7; 95% CI = 1.42-2.03), but reported lower odds of receiving a follow-up recommendation subsequent to abnormal test (78% vs 87%; OR = 0.54; 95% CI = 0.31-0.95).

CONCLUSION

Black women reported higher cervical cancer screening adherence but lower rates of being informed of an abnormal Pap test and contacted for follow-up treatment. We recommend a multilevel approach to deliver culturally appropriate education and communication for patients, physicians, clinicians in training, and clinic level ancillary staff.