Genetic counselors' implicit racial attitudes and their relationship to communication

Racial Implicit Associations in Child Psychiatry

OBJECTIVE

Racial disparities in diagnosis and treatment are prevalent in child psychiatry, including disparate diagnosis rates of internalizing and externalizing disorders in Black and White children. However, limited research has investigated mechanisms that contribute to these disparities. This study examined child racial implicit associations in psychiatric clinicians and medical students to address this gap.

METHOD

Psychiatrists and trainees completed an online survey including two race Implicit Association Tests (IATs) pairing child faces to words with either positive or negative valence, and words related to internalizing or externalizing behavioral problems. We further investigated psychiatrists and trainees' demographic predictors of implicit associations.

RESULTS

Data was analyzed from 235 psychiatrists and trainees (112 child and adolescent psychiatrists and fellows) who met inclusion criteria. Psychiatrists and trainees demonstrated greater moderate-to-strong association between Black child faces and "bad" words (44.3%) versus "good" words (6.4%), and between externalizing words (41.7%) versus internalizing words (7.2%). Psychiatrists and trainees' demographic characteristics including being female (β = -0.12; 95% CI = -0.23 to -0.01; p<0.05), Black (β = -0.36; 95% CI = -0.54 to -0.18; p<0.001), or an attending physician (β = -0.26; 95% CI = -0.45 to -0.06; p=0.01) were significant predictors of decreased association between Black child faces and negative valance words. Being female was a significant predictor of decreased association between Black child faces and externalizing words (β = -0.26; 95% CI = -0.45 to -0.06; p=0.01).

CONCLUSION

Participating psychiatrists and trainees demonstrated bias towards associating Black rather than White child faces with negative words and externalizing behavioral problems. Future research should examine 1) racial implicit associations in a more generalizable sample, 2) the relationship between race IATs and provider behavior, and 3) interventions to reduce racial inequities in psychiatry, including individual and systemic solutions.

DIVERSITY & INCLUSION STATEMENT

We worked to ensure sex and gender balance in the recruitment of human participants. We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants. We worked to ensure that the study questionnaires were prepared in an inclusive way. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented sexual and/or gender groups in science. We actively worked to promote sex and gender balance in our author group. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. One or more of the authors of this paper received support from a program designed to increase minority representation in science.

Reflections on 'common' genetic medical history questions: Time to examine the what, why, and how

OBJECTIVE

A central goal of patient-centered care is to establish a therapeutic relationship. While remaining in tune with patient emotions, genetics providers must ask questions to understand medical histories that will inform the differential diagnosis, evaluation plan, and potential treatments.

METHODS

195 audio-recorded conversations between providers and caregivers of pediatric patients with suspected genetic conditions were coded and analyzed. Coders identified sensitive history-taking questions asked by providers related to exposures and complications during pregnancy; ancestry and consanguinity; educational attainment of the caregiver; and family structure.

RESULTS

We highlight examples of providers: using stigmatizing language about conception or consanguinity; not clarifying the intent behind questions related to caregivers' educational attainment and work history; and making presumptions or assumptions about caregivers' race and ethnicity, family structure, and exposures during pregnancy.

CONCLUSION

Some questions and phrasing considered routine by genetics providers may interfere with patient-centered care by straining attempts to establish a therapeutic, trusting relationship. Additional research is needed to assess how question asking and phrasing impact rapport building and patient experience during genetics encounters.

PRACTICE IMPLICATIONS

Review of the purpose and need for medical history questions common to genetics practice could serve to improve patient-centered care.

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.

Racial disparities in cancer genetic counseling encounters: study protocol for investigating patient-genetic counselor communication in the naturalistic clinical setting using a convergent mixed methods design

BACKGROUND

Despite decades of effort to reduce racial cancer disparities, Black people continue to die at higher rates from cancer than any other U.S. racial group. Because prevention is a key to the cost-effective and long-term control of cancer, the potential for cancer genetic counseling to play a central role in reducing racial cancer disparities is high. However, the benefits of genetic counseling are not equitable across race. Only 2% of genetic counselors self-identify as Black/African American, so most genetic counseling encounters with Black patients are racially discordant. Patients in racially discordant medical interactions tend to have poorer quality patient-provider communication and receive suboptimal clinical recommendations. One major factor that contributes to these healthcare disparities is racial bias. Drawing on findings from prior research, we hypothesize that genetic counselor providers' implicit racial prejudice will be associated negatively with the quality of patient-provider communication, while providers' explicit negative racial stereotypes will be associated negatively with the comprehensiveness of clinical discussions of cancer risk and genetic testing for Black (vs. White) patients.

METHODS

Using a convergent mixed methods research design, we will collect data from at least 15 genetic counseling providers, from two different institutions, and their 220 patients (approximately equal number of Black and White patients per provider) whose appointments are for a hereditary cancer condition. The data sources will include two provider surveys, two patient surveys, video- and/or audio-recordings of genetic counseling encounters, and medical chart reviews. The recorded cancer genetic counseling in-person and telehealth encounters will be analyzed both qualitatively and quantitatively to assess the quality of patient-provider communication and the comprehensiveness of clinical discussion. Those data will be linked to pre- and post-encounter survey data and data from medical chart reviews to test our hypotheses.

DISCUSSION

Findings from this multi-site study will highlight specific aspects of cancer genetic counseling encounters (patient-provider communication and clinical recommendations) that are directly associated with patient-centered outcomes (e.g., satisfaction, trust, genetic testing completion). Patient-provider communication and clinical recommendations are modifiable factors that can be integrated into current genetic counseling training curricula and thus can have immediate impact on genetic counseling training and practice.

Applying the practice-based competencies to evaluate and characterize the contracting process within genetic counseling sessions

Contracting is a skill used by genetic counselors (GCs) to establish a shared vision for the session. Ensuring that patients and GCs are aligned on expectations for the encounter allows GCs to meet patient needs and support patient autonomy. Although contracting is described in the practice-based competencies (PBCs), the process has not been systematically observed in practice. We sought to further elucidate the skills used for contracting within genetic counseling sessions through directed content analysis of transcripts from 148 simulated prenatal and cancer genetic counseling sessions. An a priori codebook and rating scale were developed based on four contracting sample skills described in the PBCs: (a) describing the genetic counseling process, (b) eliciting client concerns, (c) applying client concerns to a session agenda, (d) modifying the agenda in response to emerging concerns. The rating scale described the quality of each skill on a 4-point scale of "absent," "minimal," "adequate," and "excellent." The codebook and rating scale were pilot tested with 40% of transcripts (n = 60). Three authors independently coded and rated the final 60% of transcripts (n = 88), resolving discrepancies via a consensus process. We found that the four PBC skills were present in most sessions (88%-98%), and on average, GCs received "adequate" scores on all four skills. We also identified three additional components of contracting not described in the PBCs: assessing whether client concerns were met, inviting to interrupt, and providing opportunity for partner concerns. This study represents the first attempt to evaluate GC performance of a PBC during a genetic counseling session. Our findings demonstrate that the PBC sample contracting skills reflect practice and suggest that they can be used in assessment of the genetic counseling contracting process. This type of analysis could be adapted in the future to provide support for other standards of practice in the genetic counseling field.

Potential influence of nurses' implicit racial bias on maternal mortality

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

An exploration of cultural competency training and genetic counselors' racial biases

Research shows genetic counselors generally have pro-White implicit biases-both prejudice and stereotyping. Cultural competency training aims to foster equitable beliefs, behaviors, and attitudes in cross-cultural genetic counseling sessions, including those that are racially discordant (genetic counselors and patients are from different racial backgrounds). Therefore, cultural competency training has the potential to mitigate bias and reduce disparities. Here, we report the prevalence of cultural competency training among genetic counselors and associations between recency of training and counselors' racial biases. We conducted an online survey of genetic counselors and trainees in fall 2021. The survey assessed four types of bias (implicit/explicit prejudice and implicit/explicit stereotyping), time since last cultural competency training, time since last communication skills training, and frequency of clinic sessions with Black patients. Multiple linear regressions modeled associations between cultural competency training and different types of bias, adjusting for communication skills training, frequency of encounters with Black patients, and counselor race (White vs. non-White). Two hundred fifteen participants (107 genetic counselors and 108 trainees) responded, and 205 reported whether they had prior cultural competency training. Of these, 187 (91%) reported ever having cultural competency training, most (53%) of participants who had training had it within 6 months prior to survey completion. We found no clear pattern of associations between cultural competency training and racial biases (implicit or explicit) in adjusted analyses. Participants who had cultural competency training four or more years prior demonstrated less negative implicit stereotyping toward Black individuals compared with those having more recent training; but no statistically significant effect was found for participants who reported never having cultural competency training, compared with those having training more recently than 4 years prior. Overall, our findings do not support that cultural competency training is negatively associated with, or mitigates, Black/White racial prejudices and stereotypes against Black patients. These findings suggest more effective interventions are needed to reduce racial biases.

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.

Racial and Ethnic Disparities in Genomic Healthcare Utilization, Patient Activation, and Intrafamilial Communication of Risk among Females Tested for BRCA Variants: A Mixed Methods Study

This study aimed to gain a deeper understanding of genomic healthcare utilization, patient activation, and intrafamilial risk communication among racially and ethnically diverse individuals tested for BRCA variants. We employed an explanatory, sequential, mixed-methods study guided by the Theory of Planned Behavior. Participants completed an online survey, including sociodemographic, medical history, and several validated instruments. A subset of participants participated in in-depth, semi-structured interviews. A total of 242 women were included in the quantitative analyses. The majority of survey participants identified as non-Hispanic white (NHW) (n = 197, 81.4%) while 45/242 (18.5%) identified as black, Indigenous, and people of color (BIPOC). The NHW participants were more likely to communicate genetic test results with healthcare providers, family, and friends than BIPOC participants (p < 0.05). BIPOC participants had lower satisfaction with testing decisions and significantly higher ratings of personal discrimination, fatalism, resilience, uncertainty, and lower patient activation scores (p < 0.05). Participants with higher education, greater satisfaction with testing decisions, and lower resilience are more likely to communicate BRCA test results with family members through the mediating effect of patient activation. Bridging disparities to ensure that genomic healthcare benefits all people may demand theory-driven, multi-level interventions targeting the individual, interpersonal, and healthcare system levels.

Health inequity in genomic personalized medicine in underrepresented populations: a look at the current evidence

Improvements in sequencing technology coupled with dramatic declines in the cost of genome sequencing have led to a proportional growth in the size and number of genetic datasets since the release of the human genetic sequence by The Human Genome Project (HGP) international consortium. The HGP was undeniably a significant scientific success, a turning point in human genetics and the beginning of human genomics. This burst of genetic information has led to a greater understanding of disease pathology and the potential of employing this data to deliver more precise patient care. Hence, the recognition of high-penetrance disease-causing mutations which encode drivers of disease has made the management of most diseases more specific. Nonetheless, while genetic scores are becoming more extensively used, their application in the real world is expected to be limited due to the lack of diversity in the data used to construct them. Underrepresented populations, such as racial and ethnic minorities, low-income individuals, and those living in rural areas, often experience greater health disparities and worse health outcomes compared to the general population. These disparities are often the result of systemic barriers, such as poverty, discrimination, and limited access to healthcare. Addressing health inequity in underrepresented populations requires addressing the underlying social determinants of health and implementing policies and programs which promoted health equity and reduce disparities. This can include expanding access to affordable healthcare, addressing poverty and unemployment, and promoting policies that combat discrimination and racism.

Implicit and explicit racial prejudice and stereotyping toward Black (vs. White) Americans: The prevalence and variation among genetic counselors in North America

Research has shown that patient experiences and outcomes of genetic counseling are not equitable across racial categories, disadvantaging Black patients relative to White patients. One major factor contributing to such racial disparities might be genetic counselor racial bias. The present study examined the prevalence of and variation in racial bias toward Black (vs. White) Americans among genetic counselors in North America. This study extends the current literature of racial disparities in experiences and outcomes of genetic counseling by distinguishing prejudice (negative feelings or attitudes) and stereotyping (beliefs) at the implicit and explicit levels as well as by including both certified genetic counselors and genetic counseling trainees. Two-hundred and fifteen genetic counselors (107 genetic counselors Board-certified by the American Board of Genetic Counseling, 108 genetic counseling trainees from Accreditation Council for Genetic Counseling accredited programs) completed four measures in a random order: the Race Implicit Association Test (IAT, for implicit prejudice), feeling thermometer (for explicit prejudice), the Medical Cooperativeness IAT (for implicit stereotyping), and a self-report measure of explicit stereotypes (for explicit stereotyping). On average, genetic counselors (both certified genetic counselors and genetic counseling trainees) were slightly to moderately in favor of White Americans over Black Americans at the implicit level. They were also slightly more likely to associate "medically cooperative" stereotypes with White Americans more than Black Americans implicitly. In contrast, genetic counselors, on average, did not display either explicit prejudice or explicit negative stereotyping, which may reflect social desirability concerns among genetic counselors. However, genetic counselors as a group strongly endorsed stereotypes related to mistrust (mistrustful of the healthcare system, skeptical of genetic testing, mistrustful of genetic counselors) to be more true for Black (vs. White) Americans. Finally, our study revealed relatively large variability in each type of bias across genetic counselors. Future research should examine how such variability in each type of bias is associated with patient experiences and outcomes of genetic counseling.

An accessible, relational, inclusive, and actionable (ARIA) model of genetic counseling compared with usual care: Results of a randomized controlled trial

PURPOSE

Effective approaches to communicate genomic information are needed to ensure equitable care. In a randomized controlled superiority trial, we tested a novel practice model that aims to make genetic counseling inclusive, by making the communication accessible, relational, and actionable (ARIA).

METHODS

In total, 696 English- and Spanish-speaking patients aged 18 to 49 years, enriched for individuals from historically underserved backgrounds, were randomized in 1:1 ratio to ARIA or usual care. Primary outcomes were accuracy of recall, communication satisfaction, and perceived understanding. In total, 33 participants completed qualitative interviews.

RESULTS

Recall and understanding were high for all participants. ARIA participants scored higher on the relationship scale of communication satisfaction (mean difference = 0.09, 95% CI = <0.01 to 0.17). Moderator analyses of communication satisfaction showed that those with lower health literacy reported less communication difficulty in ARIA and those using medical interpreters reported greater communication ease in ARIA. No significant difference was found on other primary and secondary outcomes. Qualitative data enhanced understanding of how and why ARIA can be effective.

CONCLUSION

This study provides evidence that a genetic counseling intervention that focuses on specific communication skills to enhance relationship-building, patient engagement, and comprehension can be effective with all patients and may be especially valuable for patients of lower health literacy and Spanish-speakers who use a medical interpreter.

Investigating disparity in access to Australian clinical genetic health services for Aboriginal and Torres Strait Islander people

Globally, there is a recognised need that all populations should be able to access the benefits of genomics and precision medicine. However, achieving this remains constrained by a paucity of data that quantifies access to clinical genomics, particularly amongst Indigenous populations. Using administrative data from clinical genetic health services across three Australian jurisdictions (states/territories), we investigate disparities in the scheduling and attendance of appointments among Aboriginal and/or Torres Strait Islander people, compared to non-Indigenous people. For 14,870 appointments scheduled between 2014-2018, adjusted Multivariate Poisson Regression models revealed that Aboriginal and/or Torres Strait Islander people were scheduled fewer appointments (IRR 0.73 [0.68-0.80], <0.001) and attended at lower rates (IRR 0.85 [0.78-0.93], <0.001). Within this population, adults, females, remote residents, and those presenting in relation to cancer or prenatal indications experienced the greatest disparity in access. These results provide important baseline data related to disparities in access to clinical genomics in Australia.

Patient activation reduces effects of implicit bias on doctor-patient interactions

Disparities between Black and White Americans persist in medical treatment and health outcomes. One reason is that physicians sometimes hold implicit racial biases that favor White (over Black) patients. Thus, disrupting the effects of physicians' implicit bias is one route to promoting equitable health outcomes. In the present research, we tested a potential mechanism to short-circuit the effects of doctors' implicit bias: patient activation, i.e., having patients ask questions and advocate for themselves. Specifically, we trained Black and White standardized patients (SPs) to be "activated" or "typical" during appointments with unsuspecting oncologists and primary care physicians in which SPs claimed to have stage IV lung cancer. Supporting the idea that patient activation can promote equitable doctor-patient interactions, results showed that physicians' implicit racial bias (as measured by an implicit association test) predicted racially biased interpersonal treatment among typical SPs (but not among activated SPs) across SP ratings of interaction quality and ratings from independent coders who read the interaction transcripts. This research supports prior work showing that implicit attitudes can undermine interpersonal treatment in medical settings and provides a strategy for ensuring equitable doctor-patient interactions.

Diversity training experiences and factors associated with implicit racial bias among recent genetic counselor graduates of accredited programs in the United States and Canada

Implicit racial bias in healthcare settings can impact delivery of patient care. Exploration of this bias is necessary to improve patient experiences. We sought to understand implicit racial bias among graduates of accredited genetic counseling programs in the United States and Canada in the class of 2020 as they enter the genetics workforce and assess how this bias is associated with training and life experiences. Implicit racial bias was quantified through use of the Black-White Implicit Association Test (BW-IAT). Participants also completed an online survey focused on didactic and clinical training and personal experiences with diverse populations. Participants (n = 100) were majority White (88%), and 44% demonstrated an implicit bias favoring White individuals. Respondents reported a lack of interaction with Black healthcare professionals during their training. A concerning proportion (38%) reported experiencing or witnessing racial insensitivity perpetrated by genetic counselors or physicians in supervisory roles. Graduates reported diversity coursework as significantly less effective overall than other general genetic counseling coursework. This study reveals prevalence of implicit racial bias among genetic counselor graduates, lack of exposure to diverse populations within and outside of graduate training, and concerns regarding racial insensitivity and effectiveness of didactic and clinical genetic counseling training. Employers and program directors should implement revisions to ongoing training and graduate curriculum with consideration of these findings.

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.

Implicit racial bias among medical graduates and students by an IAT measure: a systematic review and meta-analysis

INTRODUCTION

Racial implicit bias is an unconscious response and behavior that affects interpersonal interactions and clinical decision-making.

AIMS

We attempted to meta-analyze the scores of implicit association test (IAT) to estimate pooled quantity of implicit racial bias among medical graduates and students METHODS: As far as we know, our study is the first systematic-based meta-analysis estimating the pooled score of implicit racial bias among physicians and medical students. Keywords were searched in Scopus, Web of Science, Google Scholar, PubMed, Science Direct, Cochrane, MEDLINE, Wiley online library, and ProQuest databases from 2011 since 2021. The IAT's pooled score estimates through a fixed-effect meta-analysis using STATA 15. Also, I² statistic was used to determine heterogeneity across the articles.

RESULTS

Out of 1177 articles, 29 studies entered to analysis. The pooled score of IAT among physicians and medical students was 0.28 (95% CI 0.13 to 0.43) and 0.35 (95% CI 0.03 to 0.67), respectively. The racial bias score of physician ranged from -0.12 to 0.62. While score of implicit association test for medical student ranged from -0.01 to 1.29.

CONCLUSION

Our meta-analysis revealed that there was an implicit anti-black attitude among physicians and medical students, but the size of this implicit racial bias was small. Although the level of racial bias in physicians and medical students was low, it could be reduced to the lowest level through informative programs and training in ways to control implicit attitudes.

"Is that something that should concern me?": a qualitative exploration of parent understanding of their child's genomic test results

Genetic counselors are trained to deliver complicated genomic test results to parents of pediatric patients. However, there is limited knowledge on how parents perceive this information and what they understand about the results. This research aims to qualitatively explore parents’ experiences receiving genomic test results for their children. As part of formative research for the NYCKidSeq Study, we recruited a purposive sample of parents of 22 children stratified by child race/ethnicity and test result classification (positive, uncertain, or negative) and conducted in-depth interviews using a semi-structured guide. Analysis was conducted using grounded theory’s constant comparative method across cases and themes. Parents described different elements of understanding: genetics knowledge; significance and meaning of positive, uncertain, or negative results; and implications for the health of their child and family. Parents reported challenges understanding technical details and significance of their child’s results but gladly allowed their providers to be custodians of this information. However, of the different elements of understanding described, parents cared most deeply about being able to understand implications for their child’s and family’s health. These findings suggest that a counseling approach that primarily addresses parents’ desire to understand how to best care for their child and family may be more appropriate than an information-heavy approach focused on technical details. Further research is warranted to confirm these findings in larger parent cohorts and to explore ways genetic counseling can support parents’ preferences without sacrificing important components of parent understanding and overall satisfaction with their experiences with genomic medicine.

Racial Implicit Associations in Psychiatric Diagnosis, Treatment, and Compliance Expectations

OBJECTIVE

Racial and ethnic disparities are well documented in psychiatry, yet suboptimal understanding of underlying mechanisms of these disparities undermines diversity, inclusion, and education efforts. Prior research suggests that implicit associations can affect human behavior, which may ultimately influence healthcare disparities. This study investigated whether racial implicit associations exist among medical students and psychiatric physicians and whether race/ethnicity, training level, age, and gender predicted racial implicit associations.

METHODS

Participants completed online demographic questions and 3 race Implicit Association Tests (IATs) related to psychiatric diagnosis (psychosis vs. mood disorders), patient compliance (compliance vs. non-compliance), and psychiatric medications (antipsychotics vs. antidepressants). Linear and logistic regression models were used to identify demographic predictors of racial implicit associations.

RESULTS

The authors analyzed data from 294 medical students and psychiatric physicians. Participants were more likely to pair faces of Black individuals with words related to psychotic disorders (as opposed to mood disorders), non-compliance (as opposed to compliance), and antipsychotic medications (as opposed to antidepressant medications). Among participants, self-reported White race and higher level of training were the strongest predictors of associating faces of Black individuals with psychotic disorders, even after adjusting for participant's age.

CONCLUSIONS

Racial implicit associations were measurable among medical students and psychiatric physicians. Future research should examine (1) the relationship between implicit associations and clinician behavior and (2) the ability of interventions to reduce racial implicit associations in mental healthcare.

Applied Racial/Ethnic Healthcare Disparities Research Using Implicit Measures

Many healthcare disparities studies use the Implicit Association Test (IAT) to assess bias. Despite ongoing controversy around the IAT, its use has enabled researchers to reliably document an association between provider implicit prejudice and provider-to-patient communication (provider communication behaviors and patient reactions to them). Success in documenting such associations is likely due to the outcomes studied, study settings, and data structure unique to racial/ethnic healthcare disparities research. In contrast, there has been little evidence supporting the role of providers' implicit bias in treatment recommendations. Researchers are encouraged to use multiple implicit measures to further investigate how, why, and under what circumstances providers' implicit bias predicts provider-to-patient communication and treatment recommendations. Such efforts will contribute to the advancement of both basic social psychology/social cognition research and applied health disparities research: a better understanding of implicit social cognition and a more comprehensive identification of the sources of widespread racial/ethnic healthcare disparities, respectively.

An ethical framework for genetic counseling in the genomic era

The field of genetic counseling has grown and diversified since the profession emerged in the early 1970s. In the same period, genomic testing has become more complex, profitable, and widespread. With these developments, the scope of ethical considerations relevant to genetic counseling has expanded. In light of this, we find it helpful to revisit how ethical and relational variables are used to inform genetic counseling practice. Our specific focus is on whether, and to what extent, it is ethically acceptable for genetic counselors to make normative recommendations to patients. This article builds on prior literature that has critiqued nondirectiveness, a concept that has influenced and constrained the modern profession of genetic counseling since its origin. In it, we review scholarly efforts to move beyond nondirectiveness, which we believe privilege patient autonomy at the expense of other important values. We then argue that genetic counselors should favor a more explicit commitment to the principles of beneficence and non-maleficence, as well as a broader understanding of autonomy and the relational variables that impact genetic counseling. Finally, to translate our arguments into practice, we present a framework of six considerations that genetic counselors should take into account when deciding whether it is ethically acceptable, or even desirable, to make recommendations to patients in certain areas of their work.

Parent of Origin Effects on Family Communication of Risk in BRCA+ Women: A Qualitative Investigation of Human Factors in Cascade Screening

Pathogenic germline variants in Breast Cancer 1/2 (BRCA) genes confer increased cancer risk. Understanding BRCA status/risk can enable family cascade screening and improve cancer outcomes. However, more than half of the families do not communicate family cancer history/BRCA status, and cancer outcomes differ according to parent of origin (i.e., maternally vs. paternally inherited pathogenic variant). We aimed to explore communication patterns around family cancer history/BRCA risk according to parent of origin. We analyzed qualitative interviews (n = 97) using template analysis and employed the Theory of Planned Behavior (TPB) to identify interventions to improve communication. Interviews revealed sub-codes of ‘male stoicism and ‘paternal guilt’ that impede family communication (template code: gender scripting). Conversely, ‘fatherly protection’ and ‘female camaraderie’ promote communication of risk. The template code ‘dysfunctional family communication’ was contextualized by several sub-codes (‘harmful negligence’, ‘intra-family ignorance’ and ‘active withdrawal of support’) emerging from interview data. Sub-codes ‘medical misconceptions’ and ‘medical minimizing’ deepened our understanding of the template code ‘medical biases’. Importantly, sub-codes of ‘informed physicians’ and ‘trust in healthcare’ mitigated bias. Mapping findings to the TPB identified variables to tailor interventions aimed at enhancing family communication of risk and promoting cascade screening. In conclusion, these data provide empirical evidence of the human factors impeding communication of family BRCA risk. Tailored, theory-informed interventions merit consideration for overcoming blocked communication and improving cascade screening uptake.

A road map for the future: An exploration of attitudes, perceptions, and beliefs among African Americans to tailor health promotion of cancer-related genetic counseling and testing

African Americans (AA), the second largest racial/ethnic minority group in the United States (US), carry the largest mortality burden of cancer compared with other racial/ethnic groups (Cancer Facts & Figures for African Americans, 2019-2021, American Cancer Society).One solution to address this disparity is through cancer-related genetic counseling and testing (CGT). Although CGT is utilized among the general population, it remains underutilized among AA populations. Community-engaged and community-driven health promotion programs within faith-based organizations (FBOs) have been successfully implemented and delivered among AA populations (Israel et al., American Journal of Public Health, 100, 2010, 2094). FBOs are well positioned for cancer-related health promotion and equipped as conduits of health education and information distribution for cancer prevention. In the present pilot study, a community-based participatory approach (CBPR) was used to collect exploratory data on attitudes, perceptions, and beliefs toward CGT and uptake among an AA sample in the Midwest. Focus groups were conducted in two churches where respondents (N=34) answered a pre-focus group survey prior to a discussion. Respondents were largely unaware of CGT and thought of testing as primarily for ancestral discovery and not for an inheritable disease. Themes identified through qualitative analysis included emotional experiences with cancer; perception of cancer risk; different pictures of genetic testing; other things to worry about; trust in the healthcare system/faith in God and the healthcare system; and ideas and insights regarding promotion of CGT. These primary themes showed participants' perceptions of CGT were shaped by their experiences with cancer, faith, faith communities/FBOs, and cost and access to CGT. Overall, participants within these organizations had positive perceptions about the church as a conduit of genetic testing information but had mixed opinions about the rationale for completing CGT. These findings have implications for genetic counselors, medical providers, and health promotion personnel as to how AA faith populations view CGT and the utility of FBOs as promoters of CGT information.

Individuation and implicit racial bias in genetic counseling communication

OBJECTIVES

Genetic counselors (GCs) can frame information in either general terms (i.e., population risks) or individual terms (i.e., tailoring to specific client characteristics). We investigated whether informational framing might reflect GCs' implicit racial bias.

METHODS

We analyzed previously videotaped genetic counseling sessions with white and minority (Black and Latino) simulated clients (SCs) and modeled the relationship between sixty GCs' implicit racial bias, as measured by the Implicit Association Test (IAT), and informational framing (general or individual) as characterized by the Roter Interaction Analysis System.

RESULTS

Higher (more pro-white) IAT scores predicted less informational individuation for minority relative to white SCs. Similarly, higher IAT predicted fewer facilitation and activation statements to minority relative to white SCs. With higher IAT-scoring GCs, minority SCs disclosed less psychosocial and lifestyle information, and asked fewer medical questions (all p < 0.05).

CONCLUSION

GCs' racial implicit bias may be associated with less individualized communication style when counseling minority clients.

PRACTICE IMPLICATIONS

Future research should address whether increasing informational individuation can ameliorate negative consequences of implicit bias and help providers reframe perceptions of minority patients in individual rather than categorical terms.

Increasing diversity in the genetic counseling profession: Development of recruitment tools for African American undergraduate students

Lack of diversity in the genetic counseling profession has been a concern for over 20 years, with the National Society of Genetic Counselors identifying increasing diversity and inclusion as a strategic focus in 2019. Previous research has revealed potential barriers that could explain the low number of diverse applicants to genetic counseling graduate programs. The aims of this pilot study were to test strategies for participation and site recruitment methods for Historically Black Colleges and Universities (HBCUs) and to evaluate the effectiveness of a brief presentation tailored to African American students. Recruitment emails were sent to career services and 124 biology/psychology department chairs from HBCUs and one predominately white institution with over 10% black student population. There was a 16% response rate through career services and a 25% response rate from department chairs. Different sections of a single biology class at one HBCU were randomly assigned to either attend a class presentation by an African American second-year genetic counseling student and given a brochure detailing the same information (presentation group), or receive a brochure only (brochure group). Ninety students participated in the study: 65 in the presentation group and 25 in the brochure group. All students completed a 10-question knowledge test and were given an email address for further student-initiated contact about genetic counseling. In the presentation group, 65% (42/65) completed the knowledge test with a mean score of 7.59/10. Only one student from the brochure group completed the knowledge test. No students initiated contact to receive additional information about genetic counseling. This study highlights the difficulties in reaching African American students, even through HBCUs. Strategies beyond the use of brochures and presentations will be necessary to attract African American students into the genetic counseling profession.

Genetic counselor implicit bias and its effects on cognitive and affective exchanges in racially discordant simulations

Previous studies have linked clinicians' implicit racial bias with less patient-centered communication between healthcare providers and patients in a variety of healthcare contexts. The current study extends this research by exploring the influence of implicit racial bias in genetic counselors' (GCs') facilitation of simulated clients' cognitive and emotional processing during genetic counseling sessions. We conducted a secondary analysis of a nationally representative sample of genetic counseling sessions of White and ethnic and/or racial minority (Black and Latinx) simulated clients with a subset of 60 GCs who had completed a Race Implicit Association Test (IAT). Linguistic Inquiry Word Count (LIWC) was applied to session transcripts to identify word use by the simulated client consistent with emotional and cognitive processing. The Roter Interaction Analysis System (RIAS) was used to link GC statements consistent with facilitation of emotional and cognitive processing, as used in previous studies. Multiple linear regression analyses were performed to relate LIWC and RIAS variables to GC IAT scores, client race/ethnicity, and statistical interaction between GC IAT scores and client race/ethnicity. GCs used more cognitive facilitation strategies with ethnic and/or racial minority than with White clients (p = .04). There were no statistically significant associations between GCs' pro-White implicit bias and GCs' facilitation of cognitive and emotional processing or clients' use of positive, negative, or cognitive process words. While implicit bias may affect some communication processes, our analysis did not show a relationship between GC IAT score and how GCs help clients process emotional or cognitive information conveyed during a session. It is also possible that the LIWC measure of cognitive and emotional processing is not a sensitive enough measure to capture an implicit bias effect if indeed one is present.

Parent of origin differences in psychosocial burden and approach to BRCA risk management

We conducted a mixed-method study to examine coping response in BRCA+ women based on parent of origin (maternally vs paternally inherited BRCA mutation). Quantitative findings (n = 408) revealed paternally inherited cases had genetic testing later and were more likely to have a cancer diagnosis. Having a maternally inherited mutation was the strongest predictor of proactive risk management response. Qualitative interviews (n = 56) identified proactive responses among maternally inherited cases compared to reactive responses in paternally inherited cases. Findings underscore the importance of unbiased pedigree analysis to determine cancer risk. Women with paternally inherited BRCA mutations may benefit from additional psychosocial support.

Making the invisible visible: Implementing an implicit bias activity in nursing education

BACKGROUND

Implicit bias (IB) is a pervasive phenomenon that negatively impacts health outcomes. IB is unconscious bias that operates at a level in which the individual is not aware of its existence. There is no requirement to include IB content in nursing education.

PURPOSE

We sought to raise awareness of IB and its influence on health outcomes and support a discussion on ways to mitigate the impact of IB.

METHODS

Through preparatory and interactive activities, students became familiar with IB and its effects on health outcomes, completed a self-assessment using the Implicit Association Test, and engaged in a faculty-facilitated discussion. This activity was implemented at four institutions in the United States and included 110 students at the BSN, MSN and DNP levels.

RESULTS

The activity received positive evaluations. A majority of students reported the preparatory learning activities were helpful, increased awareness of their biases and felt recognition of their IB would be helpful in managing their nursing care. Student narratives are also described in this report.

CONCLUSIONS

Inclusion of IB content in nursing education is acceptable to students and faculty. The content is best included at multiple points in the course of study.

Defining and Achieving Health Equity in Genomic Medicine

The potential of genomics to improve health comes with the peril that the benefits will not be equitably available to all populations. Existing health disparities can be exacerbated if the implementation of genomic medicine does not intentionally focus on health equity. Defining what health equity means in the context of genomics and outlining how it can be achieved is important for the future of the field. Strategies to improve health equity include addressing underrepresentation of diverse populations in genomic research, investigating how genomic services can be deployed in diverse health care settings and underserved communities, increasing workforce diversity, supporting infrastructure development outside traditional research centers, and engaging communities and health care providers. By employing these strategies, the genomic research community can advance health equity in genomic medicine.

Knowledge, motivations, expectations, and traits of an African, African-American, and Afro-Caribbean sequencing cohort and comparisons to the original ClinSeq® cohort

PURPOSE

Racial minority populations are underrepresented in genomics research. This study enrolled African-descended individuals in a sequencing study and reported their characteristics.

METHODS

We purposively recruited 467 individuals self-identified as African, African American, or Afro-Caribbean to the ClinSeq^® study and surveyed them about knowledge, motivations, expectations, and traits. Summary statistics were calculated and compared with data from the study's original cohort, which was primarily White and self-referred.

RESULTS

Recruitment took five years and 83% of enrollees completed the survey. Participants had modest knowledge about benefits and limitations of sequencing (x̅s = 5.1, ranges: 0-10), and less than the original cohort (x̅ = 7.5 and 7.7, respectively). Common motivations to enroll were learning information relevant to personal health (49%) or family members' health (33%), and most had realistic expectations of sequencing. Like the original cohort, they had high levels of optimism, openness, and resilience.

CONCLUSION

Early adopters may have relatively consistent personality traits irrespective of majority/minority status and recruitment methods, but high levels of genomics knowledge are not universal. Research should determine whether recruitment and consent procedures provide adequate education to promote informed choices and realistic expectations, which are vital to ethical research and increasing genomics research participation in underrepresented communities.

Family health history and genetic services-the East Baltimore community stakeholder interview project

Discussion of family health history (FH) has the potential to be a communication tool within families and with health providers to stimulate health promotion related to many chronic conditions, including those with genetic implications for prevention, screening, diagnosis, treatment. Diverse communities with disparities in health outcomes may require different approaches to engage individuals and families in the evolving areas of genetic risk communication, assessment, and services. This work was a partnership of a local urban agency and academic genetics professionals to increase understanding of community concerns and preferences related to FH and genetic awareness. Thirty community stakeholders in the East Baltimore area participated in structured interviews conducted by community members. We identified key themes on family health history FH, risk assessment, and genetic services. Forty-three percent (18/27) of community stakeholders thought families in East Baltimore did not discuss family health history FH with doctors. Stakeholders recognized the benefits and challenges of potential actions based on genetic risk assessment and the multiple competing priorities of families. FH awareness with community engagement and genetics education were the major needs identified by the participants. Research undertaken in active collaboration with community partners can provide enhanced consumer perspectives on the importance of family health history and its potential connections to health promotion and prevention activities.

Patient and genetic counselor perceptions of in-person versus telephone genetic counseling for hereditary breast/ovarian cancer

Telephone genetic counseling (TC) for high-risk women interested in BRCA1/2 testing has been shown to yield positive outcomes comparable to usual care (UC; in-person) genetic counseling. However, little is known about how genetic counselors perceive the delivery of these alternate forms of genetic counseling. As part of a randomized trial of TC versus UC, genetic counselors completed a 5-item genetic counselor process questionnaire (GCQ) assessing key elements of pre-test sessions (information delivery, emotional support, addressing questions and concerns, tailoring of session, and facilitation of decision-making) with the 479 female participants (TC, N = 236; UC, N = 243). The GCQ scores did not differ for TC vs. UC sessions (t (477) = 0.11, p = 0.910). However, multivariate analysis showed that participant race/ethnicity significantly predicted genetic counselor perceptions (β = 0.172, p < 0.001) in that the GCQ scores were lower for minorities in TC and UC. Exploratory analyses suggested that GCQ scores may be associated with patient preference for UC versus TC (t (79) = 2.21, p = 0.030). Additionally, we found that genetic counselor ratings of session effectiveness were generally concordant with patient perceptions of the session. These data indicate that genetic counselors perceive that key components of TC can be delivered as effectively as UC, and that these elements may contribute to specific aspects of patient satisfaction. However, undefined process differences may be present which account for lower counselor perceptions about the effectiveness of their sessions with minority women (i.e., those other than non-Hispanic Whites). We discuss other potential clinical and research implications of our findings.

Mindfulness practice: A promising approach to reducing the effects of clinician implicit bias on patients

Like the population at large, health care providers hold implicit racial and ethnic biases that may contribute to health care disparities. Little progress has been made in identifying and implementing effective strategies to address these normal but potentially harmful unconscious cognitive processes. We propose that meditation training designed to increase healthcare providers' mindfulness skills is a promising and potentially sustainable way to address this problem. Emerging evidence suggests that mindfulness practice can reduce the provider contribution to healthcare disparities through several mechanisms including: reducing the likelihood that implicit biases will be activated in the mind, increasing providers' awareness of and ability to control responses to implicit biases once activated, increasing self-compassion and compassion toward patients, and reducing internal sources of cognitive load (e.g., stress, burnout, and compassion fatigue). Mindfulness training may also have advantages over current approaches to addressing implicit bias because it focuses on the development of skills through practice, promotes a nonjudgmental approach, can circumvent resistance some providers feel when directly confronted with evidence of racism, and constitutes a holistic approach to promoting providers' well-being. We close with suggestions for how a mindfulness approach can be practically implemented and identify potential challenges and research gaps to be addressed.

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

Recent evidence suggests that one possible cause of disparities in health outcomes for stigmatized groups is the implicit biases held by health care providers. In response, several health care organizations have called for, and developed, new training in implicit bias for their providers. This review examines current evidence on the role that provider implicit bias may play in health disparities, and whether training in implicit bias can effectively reduce the biases that providers exhibit. Directions for future research on the presence and consequences of provider implicit bias, and best practices for training to reduce such bias, will be discussed.

The effects of racial attitudes on affect and engagement in racially discordant medical interactions between non-Black physicians and Black patients

The association between physicians' and patients' racial attitudes and poorer patient-physician communication in racially discordant medical interactions is well-documented. However, it is unclear how physicians' and patients' racial attitudes independently and jointly affect their behaviors during these interactions. In a secondary analysis of video-recorded medical interactions between non-Black physicians and Black patients, we examined how physicians' explicit and implicit racial bias and patients' perceived past discrimination influenced their own as well as one another's affect and level of engagement. Affect and engagement were assessed with a "thin slice" method. For physicians, the major findings were significant three-way interactions: physicians' affect and engagement were influenced by their implicit and explicit racial bias (i.e., aversive racism), but only when they interacted with patients who reported any incidence of prior discrimination. In contrast, patients' affect was influenced only by perceived discrimination. Theoretical and clinical implications of current findings are discussed.

The Effects of Oncologist Implicit Racial Bias in Racially Discordant Oncology Interactions

PURPOSE

Health providers' implicit racial bias negatively affects communication and patient reactions to many medical interactions. However, its effects on racially discordant oncology interactions are largely unknown. Thus, we examined whether oncologist implicit racial bias has similar effects in oncology interactions. We further investigated whether oncologist implicit bias negatively affects patients' perceptions of recommended treatments (i.e., degree of confidence, expected difficulty). We predicted oncologist implicit bias would negatively affect communication, patient reactions to interactions, and, indirectly, patient perceptions of recommended treatments.

METHODS

Participants were 18 non-black medical oncologists and 112 black patients. Oncologists completed an implicit racial bias measure several weeks before video-recorded treatment discussions with new patients. Observers rated oncologist communication and recorded interaction length of time and amount of time oncologists and patients spoke. Following interactions, patients answered questions about oncologists' patient-centeredness and difficulty remembering contents of the interaction, distress, trust, and treatment perceptions.

RESULTS

As predicted, oncologists higher in implicit racial bias had shorter interactions, and patients and observers rated these oncologists' communication as less patient-centered and supportive. Higher implicit bias also was associated with more patient difficulty remembering contents of the interaction. In addition, oncologist implicit bias indirectly predicted less patient confidence in recommended treatments, and greater perceived difficulty completing them, through its impact on oncologists' communication (as rated by both patients and observers).

CONCLUSION

Oncologist implicit racial bias is negatively associated with oncologist communication, patients' reactions to racially discordant oncology interactions, and patient perceptions of recommended treatments. These perceptions could subsequently directly affect patient-treatment decisions. Thus, implicit racial bias is a likely source of racial treatment disparities and must be addressed in oncology training and practice.

Patient Perceptions of Telephone vs. In-Person BRCA1/BRCA2 Genetic Counseling

Telephone genetic counseling (TC) for hereditary breast/ovarian cancer risk has been associated with positive outcomes in high risk women. However, little is known about how patients perceive TC. As part of a randomized trial of TC versus usual care (UC; in-person genetic counseling), we compared high risk women's perceptions of: (1) overall satisfaction with genetic counseling; (2) convenience; (3) attentiveness during the session; (4) counselor effectiveness in providing support; and (5) counselor ability to recognize emotional responses during the session. Among the 554 participants (TC, N = 272; UC, N = 282), delivery mode was not associated with self-reported satisfaction. However, TC participants found counseling significantly more convenient than UC participants (OR = 4.78, 95 % CI = 3.32, 6.89) while also perceiving lower levels of support (OR = 0.56, 95 % CI = 0.40-0.80) and emotional recognition (OR = 0.53, 95 % CI = 0.37-0.76). In exploratory analyses, we found that non-Hispanic white participants reported higher counselor support in UC than in TC (69.4 % vs. 52.8 %; OR = 3.06, 95 % CI = 1.39-6.74), while minority women perceived less support in UC vs. TC (58.3 % vs. 38.7 %; OR = 0.80, 95 % CI = 0.39-1.65). We discuss potential research and practice implications of these findings which may further improve the effectiveness and utilization of TC.