Do Contact and Empathy Mitigate Bias Against Gay and Lesbian People Among Heterosexual First-Year Medical Students? A Report From the Medical Student CHANGE Study

The influence of sexual prejudice and gender on trait and state-level empathy

A few studies indicate that trait sexual prejudice is negatively related to trait empathy as measured by the Interpersonal Reactivity Index. Whether this association persists at the state level and is modulated by gender remains unknown. Participants read vignettes describing gay/lesbian or straight male and female characters in emotional scenarios and rated their state empathy for each character. Women reported more empathy than men and gay/lesbian targets elicited less empathy than straight targets. In addition, state empathy positively correlated with trait empathy and both negatively correlated with trait sexual prejudice. Results demonstrate that the negative association between empathy and sexual prejudice persists at the state level. We discuss our findings through the lens of social identity theory and gender roles.

An Education Intervention in Gastrointestinal Healthcare Workers Improves Knowledge of Sexual and Gender Minority Digestive Health

BACKGROUND

Sexual and gender minority (SGM) communities experience barriers in accessing healthcare. While literature exists in remedying SGM-related knowledge deficits in primary care, none exists for gastroenterology specialists.

AIMS

We detail a two-site experience with a focused education intervention for gastrointestinal healthcare workers on SGM digestive health.

METHODS

Gastroenterology and hepatology physicians, nurses, trainees, and staff at two academic medical centers participated. A 10-question pre-test and Likert scale questions on confidence in caring for sexual and gender minority patients were given. Participants then attended a lecture about SGM digestive health. After, they completed a post-test and 6-month follow-up assessment. Pre- and post-test averages of correct answers were compared to assess objective knowledge acquisition and identify gaps in knowledge.

RESULTS

Of 368 eligible participants, 143 (39.0%) completed the pre-test, 79 completed the post-test, and 93 completed 6-month follow-up. Pre-test average correct responses were 61%, while post-test correct responses increased to 70% (p < 0.001). At 6-month follow-up, average percent correct was 66% (p = 0.027 compared to pre-test). Confidence caring for SGM patients improved from 3.62 to 3.99. (1 = strongly disagree, 5 = strongly agree; p = .033). This persisted at 6 months (average 4.07, p = .007).

CONCLUSIONS

A lecture-based intervention results in significant and sustained improvement in confidence and knowledge surrounding digestive healthcare in SGM patients. This can be used as a starting point for curricular development at all medical education levels. Doing so may allow for more culturally inclusive care to be provided to SGM communities and foster cultural humility.

Lesbian, gay, bisexual, transgender, and queer health-related educational experiences in undergraduate medical curricula among Thai medical schools (LEAD-IN)

PURPOSE

In Thailand, Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) individuals face significant health disparities and discrimination in healthcare. A primary cause is the lack of knowledge among doctors and their negative attitudes towards LGBTQ people. The purpose of this study was to explore the current undergraduate medical curricula of medical schools in Thailand concerning learning outcomes, contents, teaching and learning methods, and assessment methods in the field of LGBTQ health. It also sought to gather opinions from principal stakeholders in curriculum development.

METHODS

The authors employed a mixed-methods approach with a convergent design to conduct the research. Quantitative data were collected from 23 deputy deans of educational affairs using a standardized interview form, and qualitative data were obtained through in-depth interviews with key stakeholders including 16 LGBTQ healthcare receivers, 22 medical students, and three medical teachers. Both datasets were analyzed simultaneously to ensure consistency.

RESULTS

The findings indicate that none of the medical schools had established learning objectives related to LGBTQ healthcare within their curricula. Of the institutions surveyed, 8 out of 15 (53.3%) offered some form of teaching on this topic, aligning with the qualitative data which showed 7 out of 17 institutions (41.2%) provided such education. The most frequently covered topics were gender identity and sexual orientation. Lectures were the predominant teaching method, while multiple-choice questions were the most common assessment format. There was a unanimous agreement among all principal stakeholders on the necessity of integrating LGBTQ healthcare into the M.D. program and the professional standards governed by the Thai Medical Council.

CONCLUSIONS

Although some Thai medical schools have begun to incorporate LGBTQ health into their curricula, the approach does not fully address the actual health issues faced by LGBTQ individuals. Future teaching should emphasize fostering positive attitudes towards LGBTQ people and enhancing communication skills, rather than focusing solely on the cognitive aspects of terminology. Importantly, medical educators should serve as role models in providing competent and compassionate care for LGBTQ patients.

Multidimensional Measurement of Attitudes Toward Consensual Non-Monogamy

Despite increased interest in consensual non-monogamy (CNM), significant stigma remains against CNM. Consequently, there is a need for scales to assess attitudes toward CNM. In response to this need we developed the Multidimensional Attitudes toward CNM Scale (MACS). Items were developed in consultation with content experts and data were collected from two samples at two different Canadian Universities. Fit indices of exploratory (Sample A) and confirmatory (Sample B) factor analysis suggested a 16-item scale with three underlying factors: CNM is Dysfunctional, CNM is Immoral, and CNM is Healthy and Satisfying. Validity analyses, conducted using the combined sample (n = 806; 79% women; 67% heterosexual), demonstrated that participants with higher MACS total scores (i.e. more negative attitudes) were less likely to have ever been involved in a CNM relationship and were more likely to report monogamy as their ideal relationship style. Higher MACS scores were also associated with more negative attitudes toward bisexuality and toward women, and higher scores on measures of homophobia and jealousy. In contrast, individuals with higher scores on the CNM is Healthy subscale tended to score higher on measures of empathy. The MACS demonstrates strong psychometric properties and can assist in better understanding attitudes toward CNM relationships in research and clinical settings.

Implicit bias assessment by career stage in medical education training: a narrative review

Implicit biases involve associations outside conscious awareness that lead to a negative evaluation of a person based on individual characteristics. Early evaluation of implicit bias in medical training can prevent long-term adverse health outcomes related to racial bias. However, to our knowledge, no present studies examine the sequential assessment of implicit bias through the different stages of medical training. The objective of this narrative review is to examine the breadth of existing publications that assess implicit bias at the current levels of medical training, pre-medical, graduate, and postgraduate. Protocol for this study was drafted using the Scale for the Assessment of Narrative Reviews (SANRA). Keyword literature search on peer-reviewed databases Google Scholar, PubMed, Ebsco, ScienceDirect, and MedEd Portal from January 1, 2017, to March 1, 2022, was used to identify applicable research articles. The online database search identified 1,512 articles. Full screening resulted in 75 papers meeting the inclusion criteria. Over 50% of extracted papers (74%) were published between 2019 and 2021 and investigated implicit bias at the post-graduate level (43%), followed by the graduate level (34%), and pre-medical level (9.4%). Fourteen percent were classified as mixed. Studies at the medical and medical graduate level identified an implicit preference towards white, male, non-LGBTQIA+, thin, patients. Study findings highlight notable gaps within the sequential assessment of implicit bias, specifically at the pre-medical training level. Longitudinal epidemiological research is needed to examine the long-term effect of implicit biases on existing healthcare disparities.

"Encouraged to be Your True Self": An Interpretative Phenomenological Study of Medical Students' Experiences of Role Models in Shaping Sexual Minority Identity in Medical School

Phenomenon: Sexual and gender minority (SGM) identifying individuals experience worse health outcomes compared to non-SGM identifying counterparts. Representation of SGM individuals within medical schools may improve the delivery of more equitable healthcare through reducing biases and normalizing SGM presence within healthcare spaces. Approach: Our initial aim was to explore the extent to which role models may influence personal SGM identities within medical schools in the United Kingdom, using an interpretative phenomenological approach. This methodology allowed us to develop meaning from, and give voice to participants' relationship with their bespoke experiences, respecting differing narratives within the broad 'SGM' umbrella, rather than attempting to establish commonalities. Semi-structured interviews were conducted with five medical students and three medical school faculty within three medical schools, who identified as SGM. Due to a lack of gender minority identifying participants, we unfortunately could not adequately speak to their experiences, and therefore narrowed our eventual focus to sexual minority (SM) individuals. Findings: The developed themes followed a cyclical process of: (1) role model identification; (2) role model selection, influenced by matched wider identities including generation, hierarchy and power; (3) trait assimilation, particularly where identity deficits were perceived; and (4) identity projection, where students used role models to both emulate comfortable SM identity projection, and become advocatory role models themselves. Throughout, participants described role models as multifaceted in their direction (vertical and horizontal), influence (positive and negative) and locus of effect (as individuals, and as part of a collective). Unexpectedly, identity, power, and hierarchy-matching meant peer-to-peer role modeling was often experienced more positively than vertical faculty-to-student role modeling. However, as expected, heteronormativity exerted an inhibitory effect on this process. Insights: We built upon existing social cognitive paradigms to develop a 'double-funnel' model to represent how social contexts can map onto individual SM identities and vice versa, mediated by role models. The triangulation of these three aspects in relation to medical education presents novel understandings to the field. Greater explicit institutional support of student-led SM societies, and facilitation of the presence and discussion of SM symbols and personal identities within professional spaces, may go a long way in redefining 'normativity' in medical schools.

LGBTQ+ health education for medical students in the United States: a narrative literature review

INTRODUCTION

People who identify as lesbian, gay, bisexual, transgender, queer/questioning, intersex, and other sexual/gender minorities (LGBTQ+) may experience discrimination when seeking healthcare. Medical students should be trained in inclusive and affirming care for LGBTQ+ patients. This narrative literature review explores the landscape of interventions and evaluations related to LGBTQ+ health content taught in medical schools in the USA and suggests strategies for further curriculum development.

METHODS

PubMed, ERIC, and Education Research Complete databases were systematically searched for peer-reviewed articles on LGBTQ+ health in medical student education in the USA published between 1 January 2011-6 February 2023. Articles were screened for eligibility and data was abstracted from all eligible articles. Data abstraction included the type of intervention or evaluation, sample population and size, and key outcomes.

RESULTS

One hundred thirty-four articles met inclusion criteria and were reviewed. This includes 6 (4.5%) that evaluate existing curriculum, 77 (57.5%) study the impact of curriculum components and interventions, 36 (26.9%) evaluate student knowledge and learning experiences, and 15 (11.2%) describe the development of broad learning objectives and curriculum. Eight studies identified student knowledge gaps related to gender identity and affirming care and these topics were covered in 34 curriculum interventions.

CONCLUSION

Medical student education is important to address health disparities faced by the LGBTQ+ community, and has been an increasingly studied topic in the USA. A variety of curriculum interventions at single institutions show promise in enhancing student knowledge and training in LGBTQ+ health. Despite this, multiple studies indicate that students report inadequate education on certain topics with limitations in their knowledge and preparedness to care for LGBTQ+ patients, particularly transgender and gender diverse patients. Additional integration of LGBTQ+ curriculum content in areas of perceived deficits could help better prepare future physicians to care for LGBTQ+ patients and populations.

GHB, Chemsex and Chemical Submission: Investigating the Role of Sexuality on Victim Empathy and Blame Attribution in Drug-Facilitated Sexual Assault against Men

Literature is sparse regarding men's attitudes towards male sexual assault and the role that the sexuality of those involved may have. Despite the high prevalence of chemsex and GHB (gamma-hydroxybutyrate) participation among men who have sex with men, no study has yet investigated attitudes towards such. Utilising a community sample of 141 UK men, participants were randomly assigned into one of six conditions based on victim sexuality (heterosexual or homosexual) and the drug used present during the sexual assault (chemsex, chemical submission, or no drugs). All participants completed the Male Rape Victim and Perpetrator Blaming Scale and Victim-Blaming Empathy Scale to measure victim-blame and empathy attributions. Results of a two-way MANOVA revealed a significant difference between participant gender and empathic ratings, with heterosexual participants significantly less likely to empathise than their homosexual counterparts. A non-significant difference was observed between the conditions alongside a non-significant interaction. Nevertheless, results indicate that victims in the chemsex condition, along with heterosexual victims, encountered the greatest victim-blaming attributions and the lowest rates of participant empathy overall. Findings overall appear to indicate a general decline in victim-blame attitudes towards men who have sex with men, though a level of uncertainty was apparent among the sample. Implications and limitations of the work are discussed alongside the importance of future research and psychoeducation interventions.

Treating Anxiety-Based Cognitive Distortions Pertaining to Somatic Perception for Better Chronic Pain Outcomes: A Recommendation for Better Practice in the Present Day and the Cyber Age of Medicine

Anxiety-based cognitive distortions pertaining to somatic perception (ABCD-SPs)-primarily catastrophizing, fear avoidance, and kinesiophobia-have been repeatedly linked to worsening chronic, non-cancer pain (CNCP) outcomes of increased disability, amplified pain, ineffective opioid use, and opioid misuse. Several studies have suggested that treating ABCD-SPs can improve pain outcomes, yet identification and targeting of ABCD-SPs are not part of the standard medical pain assessment and treatment plan. Utilizing a narrative review of proposed mechanisms, published patient perspectives, and study correlations connecting these cognitive distortions with CNCP outcomes, an approach for better practice in the delivery of standard medical CNCP care can be deduced and formulated into a Belief and Behavior Action Plan (BBAP) for medical clinicians treating CNCP to implement into initial and maintenance care planning. These recommendations require relatively few resources to implement and have the potential to disseminate more effective CNCP treatment on a large scale now and in the future with the new frontier of cognitive computing in medicine.

Understanding Implicit Bias and Its Impact in Veterinary Medicine

Implicit biases are those we are unwilling to admit, yet they influence our behavior in ways that impact our experience in the workplace. Literature demonstrates that implicit bias influences career choice and limits success within a chosen career. Discrimination in the veterinary workplace is pervasive and has a negative impact that is responsible for financial loss. It can also influence client communication, patient-care, and be inadvertently perpetuated by well-meaning community clinics. Strategies can be employed to acknowledge implicit bias and to foster behavioral change, which results in a healthier workplace and improved client and patient-care.

Sexual and gender minority health: a roadmap for developing evidence-based medical school curricula

Background

Educating future physicians about sexual and gender minority (SGM) patients and their health care needs is an important way to mitigate discrimination and health disparities faced by this community. Canada, across its 17 medical schools, lacks a national standard for teaching this essential topic. This paper aims to review the best practices for teaching an SGM curriculum in undergraduate medical education and synthesize this information into actionable propositions for curriculum development.

Methods

A scoping literature review was conducted to identify best practices for SGM teaching. The review elicited peer-reviewed and grey literature on best practices for SGM teaching, policy documents, and opinion pieces from medical education authorities and SGM advocacy groups. Through an iterative process with all authors, the Canadian Queer Medical Students Association (CQMSA), and the Association of Faculties of Medicine of Canada (AFMC), a set of propositions was developed.

Results

The search yielded 1347 papers, of which 89 were kept for data extraction. The main outcomes of these papers were sorted along five repeating themes, which formed the basis for six propositions; two more propositions were then added after discussion with all authors.

Conclusion

We present eight propositions for the development of a national standard for SGM education at the undergraduate medical level. These include standardizing learning objectives across all schools, using established curricular models to guide curriculum development, interweaving concepts across all levels of training, diversifying teaching modalities, providing faculty training, ensuring a safe space for SGM students and faculty, using OSCEs as a teaching tool, and involving the local SGM community in curriculum development and delivery.

An Examination of Health Care Workers' Education and Training on Their Basic Knowledge, Clinical Preparedness, and Attitudinal Awareness About LGBT Patients

LGBT individuals experience discrimination in health care settings and report difficulty accessing clinically competent healthcare. This study examined the self-assessed knowledge, clinical preparedness, LGBT health focused education received and attitudinal awareness of health care workers (HCW) (n = 215) toward LGBT patients at an urban hospital in New York City. HCW completed a one-time survey, that included the Lesbian, Gay, Bisexual, and Transgender Development of Clinical Skills Scale. Forty percent of HCW treated LGB patients and 30% treated transgender patients, 11% and 18% reported they were unaware if their patients were LGB or transgender. Seventy-four percent of HCW received less than two hours of formal education in LGBT health. A slight majority of HCW (51%) reported not receiving adequate clinical training to work with transgender clients. Forty-six percent of HCW reported not receiving adequate clinical training to work with LGB clients. A significant difference in LGBT health knowledge, clinical preparedness, and attitudinal awareness was found by LGBT health education received. HCW that reported more LGBT focused health education reported higher basic LGBT health knowledge, felt more clinically prepared, and reported affirming attitudes regarding LGBT patients. This research suggests that more LGBT health focused education of HCW is needed.

Exploring the Associations between Media and Instagram Interaction Patterns with Weight Bias among Undergraduate Nutrition Students in the Brazilian Nutritionists' Health Study

This study examined the association between media and Instagram interaction patterns with weight bias among undergraduate nutrition students in the Brazilian Nutritionists' Health Study. We also explored the potential mediating role of students' own body image perception in these relationships. A total of 406 students (78% women) participated in this cross-sectional analysis. Sociodemographic data, media influence, Instagram interaction patterns, body image perception, and weight bias were assessed using semi-structured questionnaires. Findings indicated that exposure to fitness content on Instagram (β = 0.17, p < 0.001) and the pursuit of an ideal athletic body (β = 0.12, p = 0.034) were associated with increased weight bias. In contrast, engagement with body diversity content (β = -0.23, p < 0.001) and perceived pressure from media to conform to appearance ideals (β = -0.24, p < 0.001) had a mitigating effect on weight bias. Notably, body image perception did not mediate these relationships (p > 0.05). In conclusion, this study revealed a link between media exposure and weight bias among undergraduate nutrition students, independent of their body image perception. Developing social media literacy programs that encourage students to critically evaluate media content is imperative to reduce weight bias. Additionally, a deeper examination of the media content that contributes to weight bias and the potential need for targeted regulatory measures is warranted.

"It's probably an STI because you're gay": a qualitative study of diagnostic error experiences in sexual and gender minority individuals

BACKGROUND

There is a critical need to identify specific causes of and tailored solutions to diagnostic error in sexual and gender minority (SGM) populations.

PURPOSE

To identify challenges to diagnosis in SGM adults, understand the impacts of patient-reported diagnostic errors on patients' lives and elicit solutions.

METHODS

Qualitative study using in-depth semistructured interviews. Participants were recruited using convenience and snowball sampling. Recruitment efforts targeted 22 SGM-focused organisations, academic centres and clinics across the USA. Participants were encouraged to share study details with personal contacts. Interviews were analysed using codebook thematic analysis.

RESULTS

Interviewees (n=20) ranged from 20 to 60 years of age with diverse mental and physical health symptoms. All participants identified as sexual minorities, gender minorities or both. Thematic analysis revealed challenges to diagnosis. Provider-level challenges included pathologisation of SGM identity; dismissal of symptoms due to anti-SGM bias; communication failures due to providers being distracted by SGM identity and enforcement of cis-heteronormative assumptions. Patient-level challenges included internalised shame and stigma. Intersectional challenges included biases around factors like race and age. Patient-reported diagnostic error led to worsening relationships with providers, worsened mental and physical health and increased self-advocacy and community-activism. Solutions to reduce diagnostic disparities included SGM-specific medical education and provider training, using inclusive language, asking questions, avoiding assumptions, encouraging diagnostic coproduction, upholding high care standards and ethics, involving SGM individuals in healthcare improvement and increasing research on SGM health.

CONCLUSIONS

Anti-SGM bias, queerphobia, lack of provider training and heteronormative attitudes hinder diagnostic decision-making and communication. As a result, SGM patients report significant harms. Solutions to mitigate diagnostic disparities require an intersectional approach that considers patients' gender identity, sexual orientation, race, age, economic status and system-level changes.

Integrating lesbian, gay, bisexual, transgender, and queer (LGBTQ) competency into the dental school curriculum

BACKGROUND

Decreasing healthcare disparities in marginalized communities requires healthcare providers who understand and appreciate social, economic, and cultural backgrounds. This includes care and education focused on individuals who identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ).

METHODS

This study examined dental students' and residents' self-reported clinical preparedness, prejudicial attitudes (implicit and explicit), and knowledge of health disparities that exist in the LGBTQ community using the Lesbian, Gay, Bisexual, Transgender Development of Clinical Skills Scale (LGBT-DOCSS) prior to and after the presentation of an LGBTQ competency course.

RESULTS

A total of 178 dental students at a private US dental school ranging from D1 to first-year postdoctoral residency participated in the course and completed both pre-course survey and post-course survey. Sixty-seven percent of the students reported having formal training in LGBTQ competency prior to completing the pre-training survey. The results of the LGBT-DOCSS in this population following intervention training revealed an increased feeling of clinical preparedness in treating LGBTQ patients, decreased bias toward LGBTQ, and increased knowledge of health disparities in the LGBTQ community. A more significant percentage of male respondents self-reported prejudicial beliefs. Knowledge of LGBTQ health issues increased significantly among pre-clinical students.

CONCLUSION

Introducing an early intervention LGBTQ competency course in the dental curriculum is an effective method of improving students' awareness and self-confidence in working with LGBTQ patients while decreasing biases that may have existed prior to a training course.

Palliative Care Professionals' Perceptions of Communication With Sexual and Gender Minority Patients

PURPOSE

For sexual and gender minority (SGM) individuals who identify as lesbian, gay, bisexual, transgender, queer, or any other sexual orientation or gender identity (LGBTQ+), the quality of palliative care can depend upon how clinicians view and communicate with this historically minoritized group. Prior literature has demonstrated that SGM patients access care at lower rates, and palliative care clinicians have suggested that SGM patients are more likely to experience discrimination than heterosexual patients. This study examined palliative care clinicians' perspectives and experiences regarding patient communication, care settings, the built environment, and inclusive care for SGM older adults with serious illness.

METHODS

The health disparities research framework informed a descriptive qualitative analysis of interview data with palliative care professionals (N = 20) across diverse healthcare settings within Colorado regarding their experiences and beliefs about communication and the care of SGM patients.

RESULTS

Three main themes emerged: (1) Limited sexual orientation and gender identity (SOGI) data collection; (2) Organizational and environmental inclusivity, and the "neutral" space viewed as safe; (3) Missing training platforms regarding SGM patients and a lack of opportunity to identify and discuss SGM patient needs.

CONCLUSION

Study findings illuminated the following barriers to providing SGM-inclusive care: perspectives around (1) limitations and preferences regarding collection of SOGI data, (2) organizational and environmental inclusivity, and (3) education and training regarding cultural humility and communication with SGM patients. Findings indicate the need for multidimensional research to better understand and address SGM health disparities and promote equitable care.

LGBTI Healthcare in Medical Education

ABSTRACT

Our aim is to reveal the interaction of cultural and religious influences with professional equipment by determining the level of knowledge, sexual attitudes, and homophobia of medical students about LGBTI+ individuals. The study included 324 students from our faculty of medicine. The Hudson and Ricketts Homophobia scale, the Attitudes Towards Lesbians and Gay Men scale, and the Hendrick Sexual Attitudes scale were used with the sociodemograpic data form. Data were collected and analyzed using descriptive and inferential statistical tests. The mean score of the students from the Hudson and Ricketts Homophobia scale was 58.50. The findings of our study support that medical students consider that the education they receive in this regard is inadequate. One of the goals of undergraduate medical education is the provision of health services to all segments of society; therefore, it is recommended to make improvements in the curriculum in this regard.

Student's perspectives of inclusive practices in anatomy education

There is a drive to implement inclusive practices in anatomy by adapting curricula and utilizing inclusive language and resources that negate biases. However, to date there is no data regarding student's perception of inclusivity. Therefore, the study aims to investigate anatomy student's opinions on inclusive practices in anatomy education based on the protected characteristics of age, disability, ethnicity, gender affirmation and sex. One hundred and forty-five students completed a questionnaire with 21 Likert-scale and two open-ended questions. Kruskal-Wallis tests compared responses by groups defined by the protected characteristics of the Equality Act (2010). Most students (71.2%; n = 84) agreed or strongly agreed that "improving inclusivity in anatomy education should be educator's priority". In terms of representation, there was a statistically different response rate from students from different ethnic backgrounds to the statements "there are anatomy educators" (p < 0.001), "images in textbooks" (p < 0.001) and "models in the dissection room" (p < 0.001) "that look like me". Most students agreed or strongly agreed to statements relating to the protected characteristics of age (70.4%; n = 68), disability (78.6%; n = 77), ethnicity (59.8%; n = 64), gender affirmation (46.3%; n = 46) and sex (51.5%; n = 62). Themes identified relating to improving inclusivity included "reflecting reality", "teaching the truth", "the invisibility of women" and the "learning environment". Students have confirmed that anatomists, as gatekeepers of the knowledge of the human body, should foster inclusive teaching practices that will benefit all students and potentially future patient care.

Intergroup Contact Improves Medical Student Attitudes and Skill in Transgender Health Care

Purpose

Poorer health outcomes for transgender and gender diverse (TGD) individuals have been associated with lack of health care provider knowledge and personal bias. Training at all levels of medical education has been positioned as one strategy to combat these inequities. This study sought to characterize preclinical medical student attitude, skill, and knowledge pre- and post-teaching with TGD community volunteers.

Methods

This matched pre- and post-test study was conducted from July 2020 to August 2021 capturing two preclinical medical student cohorts exposed to the same teaching intervention. Students completed the Transgender Attitudes and Beliefs Scale (TABS) and the Transgender Development of Clinical Skills Scale (T-DOCSS) at baseline, 1 week, and 1 month after the clinical skills session. Tutors' attitudes to TGD health were measured before facilitating teaching, using the Attitudes Toward Transgender Patients and Beliefs and Knowledge about Treating Transgender Patients scales.

Results

Fifty-nine students completed questionnaires at three time points and were included in this study. Total TABS and T-DOCCS scores increased from preintervention to 1-week follow-up, maintained at 1 month, with significant changes in Interpersonal Comfort and Sex and Gender Beliefs subscales. Scores on the Human Value subscale did not change, remaining consistently high. Postintervention knowledge-question scores were high. Nine of 13 tutors completed surveys, demonstrating overall positive attitudes toward gender diversity and TGD health.

Conclusion

This study demonstrates improvement in preclinical medical student attitudes and self-reported skill toward gender health care sustained at 1 month after small-group teaching with TGD community volunteers.

Sexual Orientation and Racial Bias in Relation to Medical Specialty

Physician explicit and implicit biases involving race and sexual orientation (SO) affect patient and provider experiences in healthcare settings. An anonymous survey was disseminated nationally to graduating medical students, residents, and practicing physicians to evaluate SO and racial biases across medical specialties. SO explicit and implicit bias were measured with the Attitudes toward Lesbians and Gay Men Scale, short form (ATLG-S) and Gay-Straight Implicit Association Test (IAT). Racial explicit and implicit bias were measured with the Quick Discrimination Index (QDI) and the Black-White IAT. Medical specialty was associated with racial explicit bias and specialty prestige with Black-White IAT score. Medical specialty and specialty prestige were not associated with SO bias. Female sex, sexual and gender minority (SGM) identity, and decreased religiosity were associated with reduced SO and racial bias. Provider race was associated with racial implicit and explicit bias.

Characterization of content associated with lesbian, gay, bisexual, transgender, intersex, and queer individuals in Chilean medical schools: a cross-sectional survey

BACKGROUND

Lesbian, gay, bisexual, transgender, intersex, queer, and other sexual and gender identities (LGBTIQ+) individuals face health inequities. Additionally, medical students report a lack of confidence in providing specific health care to LGBTIQ + individuals, and medical schools do not offer the breadth and depth of coverage needed to fully prepare and make them comfortable in caring for these individuals. This study aims to characterize the teaching of curricular content related to LGBTIQ + health issues in medical schools in Chile.

METHODS

This was a cross-sectional descriptive mixed-methods study based on a 15-question survey sent to school directors of the 24 medical schools in Chile, conducted between October 2020 and July 2021. The questions included in the study were mostly based on two pre-existing questionnaires covering content, assessment methods, and identification of barriers to teaching this content.

RESULTS

The validated questionnaire was answered by 14 of 24 Chilean medical schools, with 11 schools (78.9%) declaring that they included some training in their curriculum. The predominant range of time allocated to LGBTIQ + training in medical programs was between 1 and 5 h. The most addressed topics were HIV (92.85%), sexual orientation (78.57%), and chronic disease risk in LGBTIQ + populations (78.57%). Most schools, accounting for 71.5%, considered the content they delivered to be "moderately insufficient" or "insufficient". Regarding the teaching methodologies, the most used were lectures (92.8%), clinical cases (42.9%), and clinical simulation (28.6%).

CONCLUSION

Most surveyed medical schools reported curricular spaces dedicated to teaching health issues of LGBTIQ + individuals, primarily during the pre-internship training period. However, the time allocated is insufficient, and there is little approach to topics beyond the patient's sexual history or sexual orientation. Given the crucial role of medical schools, they must adopt both local and national strategies to enrich training focused on the care of LGBTIQ + patients.

Assisted Reproduction for a Same-Sex Couple: Interdisciplinary Preclinical Active Learning Module Combining Case-Based Small Group Discussion and Patient Panel

OBJECTIVE

Physicians often feel they are not equipped to serve the lesbian, gay, bisexual, and queer (LGBTQ) community, but integrating education that incorporates LGBTQ content and perspective into an already-condensed medical school curriculum is challenging. We developed a preclinical active learning module on assisted reproductive technologies (ART) in LGBTQ care, integrating clinical and basic science content with patient perspective.

METHODS

We created a module that combined a case-based small group discussion with a patient panel. We developed a case for discussion in collaboration with a female cis-gender same-sex couple who conceived through ART. A patient panel with the same couple followed the discussion. All first-year medical students attended both parts of the module. Prior to participation, students learned reproductive endocrinology and genetics concepts through lectures. After the module, students voluntarily completed an anonymous survey to evaluate self-perceived changes in familiarity and confidence with LGBTQ patients and satisfaction with the module.

RESULTS

Of the 126 students who attended, 72 (57%) completed the survey. Of these, 69 (95.8%) felt the module gave them better perspectives on LGBTQ patient experiences, and 66 to 69 (92-96%) agreed the small group discussion achieved its learning objectives on LGBTQ health barriers and the application of ART. Students valued the patient panel (84.7%) and cited a better understanding of reproductive barriers for LGBTQ patients as its most valuable point.

CONCLUSION

A preclerkship module combining a case-based small group discussion and patient panel on ART delivered in the context of a real-life LGBTQ patient experience provided an opportunity for the students to integrate basic science and clinical science knowledge to reflect on the healthcare needs of this patient population. Creating the case in collaboration with the same-sex couple and having them present their own experience provided an authentic perspective to students on reproductive healthcare issues and how they impact members of the LGBTQ community.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Immigration bias among medical students: a randomized controlled trial

BACKGROUND AND IMPORTANCE

Racial bias is found in both physicians and medical students. Immigrants in many parts of the world face challenges similar to racial minorities. Identification of immigrants might however be more subtle than identification by race, and currently, no data are available on a possible bias against the large minority group of migrants in Europe.

DESIGN

Randomized control trial.

SETTINGS AND PARTICIPANTS

Second-year medical students were randomized into four groups to watch a video of either a male or female patient with pain, with or without immigrant status.

INTERVENTION

Students were asked whether they would administer pain medication (primary outcome).

OUTCOME MEASURES AND ANALYSIS

Immigrant status, patient's gender, student's gender, age, and language skills were covariates in a logistic regression model. Secondary outcomes included pain medication potency and the student's rating of the patient's pain intensity.

MAIN RESULTS

We recruited 607 students [337 females (56%), 387 (64%) between 18 and 22 years old]. Analgesia was administered in 95% (n = 576). Immigrant status was not associated with the probability of receiving pain medication [95 vs. 95%, odds ratio (OR) 0.81, 95% confidence interval (CI) 0.39-1.70, P  = 0.58]. Immigrants received high-potency analgesia less often (26 vs. 33%, OR 0.69, 95% CI 0.50-0.96, P  = 0.03). Female students administered pain medication more frequently (96 vs. 93%, OR 2.29, 95% CI 1.05-5.02, P  = 0.04), and rated the patients' pain higher (mean numeric rating scale 7.7, SD 0.9 vs. 7.4, SD 1.0, OR 1.36, 95% CI 1.16-1.60, P  < 0.001).

CONCLUSION

Medical students showed no immigration bias with regard to administering pain medication but were less likely to choose high-potency analgesia in immigrants. We also found a gender difference in pain management. These results demonstrate the importance of including knowledge about immigration bias in medical training.

Weight bias reduction intervention among nurse practitioner students using simulation-based experiences

ABSTRACT

Few nurse practitioner (NP) programs include obesity and weight bias education in their curriculum. However, NPs will likely provide care for people living with obesity, many of whom have been discriminated against based on their weight by previous providers, and many NP students may feel unprepared to navigate weight management competently. This pilot study included a weight bias reduction (WBR) intervention, which included a simulation-based experience (SBE) with a standardized participant (SP) and educational activities embedded within the NP curriculum. Nineteen NP students participated in this pilot study, but only seven students had matching data for preintervention to postintervention scores. There were no statistically significant differences in preintervention and postintervention Attitudes Toward Obese Persons (ATOP) or Beliefs About Obese Persons (BAOP) scores. Despite this small sample size and not achieving statistical significance, SBE-SP holds promise to depict realistic patient encounters to improve NPs' attitudes and beliefs toward persons with obesity and to reduce weight bias. Therefore, incorporating SBE-SP may be a feasible component of the NP curriculum.

Transgender Attitudes and Beliefs Scale-Greek (TABS-Gr) version: translation and initial evaluation of psychometric properties among medical students

BACKGROUND

Transgender people face significantly greater discrimination and health disparities in health care settings than cisgender people. The role of education in eliminating this phenomenon has been increasingly recognized by many medical schools. However, transgender health content is sparse or lacking in the medical curricula of many countries.

METHOD

This study was designed to validate the Greek version of the Transgender Attitudes and Beliefs Scale (TABS-Gr). The study adopted a cross-sectional, comparative-descriptive research design. Participants (N = 203) were contacted through online recruitment and invited to complete an anonymous web-based survey. The data were collected between December 2022 and February 2023.

RESULTS

The overall reliability of the TABS-Gr questionnaire was high (Cronbach's α = 0.961, p. from Hotelling's T-squared test < 0.000). High Cronbach's alpha values were estimated for the three subscales, with α = 0.958 for Interpersonal Comfort, α = 0.906 for Gender Beliefs, and α = 0.952 for Human Values. Hotelling's T-squared test confirmed that all items on the scale had the same mean (p < 0.001 for all subgroups). Explanatory factor analysis (EFA) demonstrated adequate fit. Convergent and discriminant validity were validated based on the estimated correlations. The three-factor structure of the Greek TABS version was confirmed. The mean total score was 155.95 (SD = 30.63), indicating that medical students had a moderately positive attitude towards transgender people. Participants showed significantly less biased (more tolerant, positive) attitudes towards transgender people on the Interpersonal Comfort (IC) and Human Value (HV) subscales than on the Sex/Gender Beliefs (SGB) subscale. A demographic comparison was conducted and demonstrated a correlation between scores and sociodemographics, except for place of origin. A statistically significant increase in the total mean score was estimated for women compared to men.

CONCLUSION

The overall psychometric findings provide some evidence to support the validity of the Greek version of the TABS. However, we call for further validation research in Greek medical schools. Since our claims for validity are based in part on an exploratory factor analysis, a future confirmatory factor analysis (CFA) is part of our call for further validation research. While the results of this study are mostly in line with the results of previous research, some nuances were identified. These results may inform educators, medical school curricula and education policy-makers.

Developing medical professionalism in care of gender nonconforming patients: Reflections of second-year medical students after a curricular experience with gender nonconforming people and allies

INTRODUCTION

Negative healthcare experiences persist for gender nonconforming individuals. Clinician-related factors, including lack of comfort with gender nonconforming persons and unexamined personal biases, present barriers to equitable and affirming healthcare. We explored the effects of contact with gender nonconforming individuals in preclinical medical education through a structured curricular intervention designed to build medical and humanistic knowledge and stimulate the development of medical professionalism surrounding the care of gender nonconforming individuals.

METHODS

A curricular module (didactic prework, time-synchronous online panel discussion, and post-event written reflection) was implemented in a second-year preclinical course in a large multi-campus Midwestern medical school. The module was based on pedagogical foundations of contact theory and reflective writing. Post-event written reflections were investigated using thematic analysis.

RESULTS

Analysis of 355 written reflections revealed three major themes (moments of insight, topics of confusion, connections to professional identity formation) and eight sub-themes. The findings demonstrated emerging gender professionalism and the importance of contact in professional development.

DISCUSSION

Contact with gender nonconforming people and the use of written reflections can encourage self-examination and foster professional identity formation among preclinical medical students. Modeling gender-affirming approaches may help counteract negative cultural messages about gender nonconforming people, aiding development of inclusive future physicians.

Patient representation in New Zealand general practice and rural health case-based teaching: a quality improvement exercise

Introduction Healthcare inequity disproportionately affects minority populations in Aotearoa New Zealand. Healthcare providers may contribute to inequity due to their biases. Medical education can unintentionally promote biases by reinforcing stereotypes or limiting exposure to diversity. Teaching staff from the Department of General Practice and Rural Health suggested a need to review current teaching materials to ascertain if they have the potential to contribute to this bias. Aim The aim of this study was to review case-based teaching material to determine its representation of the New Zealand population, and whether there is potential to contribute to implicit bias. Methods Document analysis of 135 cases used to teach fourth- and fifth-year medical students in the Department of General Practice and Rural Health, Otago Medical School was performed. Demographic, clinical and social features of each case were recorded and analysed. Results Cases typically included patient age (129/135, 95.6%), sex (127/135, 94.1%) and occupation status (91/136, 66.9%). Ethnicity (31/135, 23.0%), living situation (55/135, 40.7%), relationship status (57/135, 42.2%) and sexual orientation (52/135, 40.0%) were less frequently defined. Cases typically represented the population majority norms. Discussion Case-based teaching materials require regular review and updating to match population demographics. There is potential to improve representation of diversity, and hence cultural safety, though review and revision of written teaching cases.

The Impact of Sexual Violence on Quality of Life and Mental Wellbeing in Transgender and Gender-Diverse Adolescents and Young Adults: A Mixed-Methods Approach

Transgender (trans) and gender-diverse (GD) adolescents and young adults have remained largely invisible in health research. Previous research shows worse outcomes in health indicators for trans and GD people, compared to cisgender controls. Research on the impact of sexual violence focuses on mainly cisgender female adult victims. This study assessed the impact of sexual violence on the quality of life (QoL) and mental wellbeing (GHQ-12) among trans and GD adolescents and young adults, while taking into account the possible role of gender nonconformity in sexual violence and mental wellbeing. An online, anonymous survey and interviews/focus groups were conducted between October 2021 and May 2022 in Belgium. Multiple analyses of covariance (ANCOVAs) were used to assess the associations between sexual violence, mental wellbeing, and gender nonconformity, while controlling for different background variables (gender identity, sexual orientation, age, economic vulnerability, etc.). The interviews and focus groups were used to validate associations between variables that were hypothesized as important. The quantitative sample consisted of 110 respondents between 15 and 25 years old, with 30 trans respondents (27.3%) and 80 GD respondents (72.7%). A total of 73.6% reported experiences with sexual violence over the past two years (n = 81). The mean QoL score was 5.3/10, and the mean GHQ-12 score was 6.6/12. Sexual violence was not significantly associated with QoL (p = 0.157) and only marginally significantly associated with GHQ-12 (p = 0.05). Changing one's physical appearance to conform to gender norms, out of fear of getting attacked, discriminated against, or harassed was significantly associated with QoL (p = 0.009) and GHQ-12 (p = 0.041). The association between sexual violence and changing one's physical appearance to conform to gender norms was analyzed, to assess a possible mediation effect of sexual violence on mental wellbeing. No significant association was found (p = 0.261). However, the interviews suggest that sexual violence is associated with changing one's physical appearance, but this association is not limited to only trans and GD victims of sexual violence. Non-victims also adjust their appearance, out of fear of future sexual victimization. Together with the high proportion of sexual violence, as well as the lower average QoL and higher average GHQ-12 scores among trans and GD adolescents and young adults, compared to general population statistics, this highlights the need for policy makers to create more inclusive environments.

LGBTQ + cultural competency training for health professionals: a systematic review

BACKGROUND

Health disparities experienced by LGBTQ + individuals have been partially attributed to health professionals' lack of cultural competence to work with them. Cultural competence, the intricate integration of knowledge, skills, attitudes, and behaviors that improve cross-cultural communication and interpersonal relationships, has been used as a training framework to enhance interactions between LGBTQ + patients and health professionals. Despite multiple published LGBTQ + cultural competency trainings, there has been no quantitative appraisal and synthesis of them. This systematic review assessed articles evaluating the design and effectiveness of these trainings and examined the magnitude of their effect on cultural competence outcomes.

METHODS

Included studies quantitatively examined the effectiveness of LGBTQ + cultural competency trainings for health professionals across all disciplines in various healthcare settings. 2,069 citations were retrieved from five electronic databases with 44 articles meeting inclusion criteria. The risk of bias in the included studies was assessed by two authors utilizing the Joanna Briggs Institute critical appraisal checklists. Data extracted included study design, country/region, sample characteristic, training setting, theoretical framework, training topic, modality, duration, trainer, training target, measurement instrument, effect size and key findings. This review followed the PRISMA statement and checklist to ensure proper reporting.

RESULTS

75% of the studies were published between 2017 and 2023. Four study designs were used: randomized controlled trial (n = 1), quasi-experimental pretest-posttest without control (n = 39), posttest only with control (n = 1) and posttest only without control (n = 3). Training modalities were multiple modalities with (n = 9) and without simulation (n = 25); single modality with simulation (n = 1); and with didactic lectures (n = 9). Trainings averaged 3.2 h. Ten studies employed LGBTQ + trainers. The training sessions resulted in statistically significant improvements in the following cultural competence constructs: (1) knowledge of LGBTQ + culture and health (n = 28, effect size range = 0.28 - 1.49), (2) skills to work with LGBTQ + clients (n = 8, effect size range = 0.12 - 1.12), (3) attitudes toward LGBTQ + individuals (n = 14, effect size range = 0.19 - 1.03), and (4) behaviors toward LGBTQ + affirming practices (n = 7, effect size range = 0.51 - 1.11).

CONCLUSIONS

The findings of this review highlight the potential of LGBTQ + cultural competency training to enhance cultural competence constructs, including (1) knowledge of LGBTQ + culture and health, (2) skills to work with LGBTQ + clients, (3) attitudes toward LGBTQ + individuals, and (4) behaviors toward LGBTQ + affirming practices, through an interdisciplinary and multi-modal approach. Despite the promising results of LGBTQ + cultural competency training in improving health professionals' cultural competence, there are limitations in study designs, sample sizes, theoretical framing, and the absence of longitudinal assessments and patient-reported outcomes, which call for more rigorous research. Moreover, the increasing number of state and federal policies that restrict LGBTQ + health services highlight the urgency of equipping health professionals with culturally responsive training. Organizations and health systems must prioritize organizational-level changes that support LGBTQ + inclusive practices to provide access to safe and affirming healthcare services for LGBTQ + individuals.

Integrating LGBTQIA + Community Member Perspectives into Medical Education

ProblemLGBTQIA+ (lesbian, gay, bisexual, transgender, queer, intersex, asexual, and all sexual and gender minorities) people have unique health care needs related to their sexual orientation, gender identity and expression, and sex development. However, medical education has historically excluded LGBTQIA + health-related content in formal curricula. It is common for medical students to interact with diverse patient populations through clinical rotations; however, access to and knowledge about LGBTQIA + patients is inconsistently prioritized in medical schools. This is especially true for LGBTQIA + patients with intersecting historically marginalized identities, such as people of color and people with disabilities. Learning from and listening to medically underserved community members can help both medical students and educators better understand the unique health needs of these communities, and address implicit biases to improve health care and outcomes for their patients. Intervention: To address the lack of LGBTQIA + health-related content in medical education and improve access to and knowledge about LGBTQIA + patients, LGBTQIA + community members' perspectives and lived experiences were integrated into undergraduate medical education via four primary methods: Community Advisory Groups, community panel events, standardized patients, and community member interviews. Context: LGBTQIA + community members' perspectives and lived experiences were integrated into medical education at Harvard Medical School (HMS) as part of the HMS Sexual and Gender Minority Health Equity Initiative. Impact: LGBTQIA + community members' perspectives and lived experiences were successfully integrated into multiple aspects of medical education at HMS. During this process, we navigated challenges in the following areas that can inform similar efforts at other institutions: representation of diverse identities and experiences, meeting and scheduling logistics, structural barriers in institutional processes, and implementation of community member recommendations. Lessons Learned: Based on our experiences, we offer recommendations for integrating LGBTQIA + community members' perspectives into medical education. Engaging community members and integrating their perspectives into medical education will better enable medical educators at all institutions to teach students about the health care needs of LGBTQIA + communities, and better prepare medical students to provide affirming and effective care to their future patients, particularly those who are LGBTQIA+.

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

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

Are Medical Students More Prejudiced? Comparison of University Students' Attitudes Towards Sexual Minorities by Faculties and Cultural background: A Study From Hungary

Sexual and gender minorities often experience discrimination or stigmatization during health encounters. When patients feel stigmatized, they are more likely to delay seeking help and it affects patient cooperation and compliance, thus undermining therapeutic efficacy itself. We examined knowledge and attitude toward LGBT+ people among Hungarian (n = 743) and foreign (n = 130) medical students of the four Hungarian medical universities and 188 students from other faculties. Homonegativity and inadequate knowledge about sexual minority individuals are correlated with male gender, conservative political views, religiosity, religious behavior, and the absence of LGBT+ acquaintance. Medical students show more negative attitudes than students from other disciplines, although foreign medical students were more accepting than Hungarian program students. Further investigation of sexual minority-related content of the Hungarian medical education and revising the written and hidden curriculum would be desired, as well as collecting data from postgraduate students, physicians, and wide range of university faculties.

Designing a neuroclinical assessment of empathy deficits in psychopathy based on the Zipper Model of Empathy

Ho, M.H., Kemp, B.T., Eisenbarth, H. & Rijnders, R.J.P. Designing a neuroclinical assessment of empathy deficits in psychopathy based on the Zipper Model of Empathy. NEUROSCI BIOBEHAV REV YY(Y) XXX-XXX, 2023. The heterogeneity of the literature on empathy highlights its multidimensional and dynamic nature and affects unclear descriptions of empathy in the context of psychopathology. The Zipper Model of Empathy integrates current theories of empathy and proposes that empathy maturity is dependent on whether contextual and personal factors push affective and cognitive processes together or apart. This concept paper therefore proposes a comprehensive battery of physiological and behavioral measures to empirically assess empathy processing according to this model with an application for psychopathic personality. We propose using the following measures to assess each component of this model: (1) facial electromyography; (2) the Emotion Recognition Task; (3) the Empathy Accuracy task and physiological measures (e.g., heart rate); (4) a selection of Theory of Mind tasks and an adapted Dot Perspective Task, and; (5) an adjusted Charity Task. Ultimately, we hope this paper serves as a starting point for discussion and debate on defining and assessing empathy processing, to encourage research to falsify and update this model to improve our understanding of empathy.

Explicit and implicit weight bias among health care students: a cross-sectional study of 39 Australian universities

Background

Weight bias exhibited by health care students may continue into their future practice, compromising the provision of care that people living with overweight or obesity receive. This highlights the need to comprehensively examine the extent to which weight bias is present among health care students and the factors that may be associated with students' weight bias.

Methods

In this cross-sectional study, Australian university students enrolled in health care courses were invited via social media advertisements, snowball and convenience sampling, and by making direct contact with universities to complete an online survey. Students provided demographic information including discipline of study, perceived weight status, and state of residence. Students then completed several measures which assessed their explicit and implicit weight bias, and empathy. Descriptive statistics established the presence of explicit and implicit weight bias, and ANCOVAs, ANOVA, and multiple regression analyses were conducted to examine the potential factors associated with students' exhibited weight bias.

Findings

Between March 08, 2022, and March 15, 2022, 900 eligible health care students attending 39 Australian universities participated in the study. Students reported varying levels of explicit and implicit weight bias, with minimal differences between disciplines on most outcome measures. Students who identified as men (vs. women) exhibited higher of both explicit and implicit bias (Beliefs About Obese Persons (BAOP): p = 0.0002, Antifat Attitudes Questionnaire (AFA)-Dislike: p = 0.019, AFA Willpower p < 0.0001, Empathy for Obese Patients: p = 0.0011, Implicit Association Test: p = 0.022), and students who displayed greater (vs. less) empathic concern exhibited lower levels of explicit bias (BAOP, AFA Dislike and Willpower, and Empathy for Obese Patients: p < 0.0001). Having witnessed the enactment of weight stigma sporadically (vs. regularly) by role models was associated with greater attribution of the causes of obesity to willpower (a few times a month vs. daily: p = 0.020, a few times a year vs. daily: p = 0.022), and less time spent with people living with overweight or obesity outside of study was associated with more dislike (a few times a month vs. daily: p = 0.0048, once a month vs. daily: p = 0.0002) and less fear of fat (once a month vs. daily: p = 0.036, and once a month vs. a few times a week: p = 0.0028).

Interpretation

Results demonstrate the presence of both explicit and implicit weight bias among Australian health care students. Several characteristics and experiences of students were associated with their weight bias. Validity of the exhibited weight bias should be established in practical interactions with people living with overweight or obesity and novel interventions should be developed to ameliorate weight bias.

Funding

Research Training Program (RTP) Scholarship, Australian Government, Department of Education.

A Call for the Creation of LGBTQ+ Competencies for Hospice and Palliative Medicine (HPM) Fellowship Programs

CONTEXT

LGBTQ+ people and their families have unique needs, concerns, and issues when navigating serious illness.

OBJECTIVES

To develop curricular milestones and an educational framework for hospice and palliative medicine (HPM) fellowship programs to meet the needs of this community.

METHODS

A working group has developed a plan for the inclusion of LGBTQ+ competencies in HPM fellowship programs, utilizing input from an AAHPM Special Interest Group (SIG) at a national meeting.

DISCUSSION

Learning to provide culturally competent care is essential for all HPM providers. Our group recommends specific clinical training competencies with plans to pilot them in upcoming academic years. Creating curricular recommendations will help guide fellowship programs education in the care of LGBTQ+ patients with serious illness.

Disclosure and comfort during genetic counseling sessions with LGBTQ+ patients: An updated assessment

Disclosure is the act of sharing a stigmatized identity, and members of the LGBTQ+ community make decisions related to disclosure multiple times throughout their life. Disclosure in medical settings can impact perceptions of care and outcomes for LGBTQ+ patients; however, little is understood about the process of decision-making regarding disclosure in the genetic counseling setting. As such, this study aimed to explore LGBTQ+ experiences in genetic counseling sessions and their disclosure behaviors. Fifty-five LGBTQ+ individuals who attended a genetic counseling session and 91 genetic counselors completed online surveys. The patient survey assessed for disclosure behaviors, experiences of discrimination, and comfort in genetic counseling sessions. The counselor survey evaluated comfort with the LGBTQ+ population in a counseling setting, whether counselors facilitate disclosure in sessions, and whether counseling is tailored for the LGBTQ+ population. Eighty-two percent of genetic counselors "rarely" or "never" ask about sexual orientation, and 69% "rarely" or "never" ask about gender identity. The majority of patients indicated they were not asked about their sexual orientation (87%) or gender identity (80%). Some patients reported experiencing discrimination or homo/transphobia in their genetic counseling sessions, with 6.12% of LGBQ+ patients experiencing discrimination and 24.1% of trans+ patients reporting discrimination. Over half of genetic counselors reported receiving training in LGBTQ+ healthcare and the majority reported comfort with providing care to LGBTQ+ patients. However, discrepancies between patient-reported experiences and genetic counselors' descriptions of their care for the LGBTQ+ population warrant further research and suggest additional training or changes in practice may be necessary.

Factors influencing LGBTQ+ disclosure decision-making by Canadian health professionals: A qualitative study

Disclosure of LGBTQ+ identities at work may reap benefits, but may also exacerbate harms. Faced with ambiguous outcomes, people engage in complex concealment/disclosure decision-making. For health professionals, in contexts of pervasive heteronormativity where disclosure to patients/clients is deemed to violate professional boundaries, stakes are high. This qualitative study with 13 LGBTQ+ health professionals across Canada used semi-structured interviews to explore factors affecting disclosure decision-making, particularly attending to power structures at multiple levels. Most participants engaged in constant risk-benefit assessment, disclosing strategically to colleagues, rarely to clients/patients. At the individual level they were affected by degree of LGBTQ+ visibility. At the institutional level they were affected by the culture of particular professional fields and practice settings, including type of care and type of patients/clients, as well as colleague interactions. Professional power-held by them, and held by others over them-directly affected disclosures. Finally, intersections of queer identities with other privileged or marginalized identities complicated disclosures. Power relations in the health professions shape LGBTQ+ identity disclosures in complex ways, with unpredictable outcomes. Concepts of professionalism are infused with heteronormativity, serving to regulate the gender and sexual identity expression of queer professionals. Disrupting heteronormativity is essential to forge more open professional cultures.

Protocol for the pilot quasi-experimental controlled trial of a gender-responsive implementation strategy with providers to improve HIV outcomes in Uganda

BACKGROUND

Antiretroviral treatment (ART) is the most effective clinical intervention for reducing morbidity and mortality among persons living with HIV. However, in Uganda, there are disparities between men and women in viral load suppression and related HIV care engagement outcomes, which suggests problems with the implementation of ART. Gender norms are a known driver of HIV disparities in sub-Saharan Africa, and patient-provider relationships are a key factor in HIV care engagement; therefore, the role of gender norms is important to consider in interventions to achieve the equitable provision of treatment and the quality of ART counseling.

METHODS

The overall research objective of this study is to pilot test an implementation strategy (i.e., methods to improve the implementation of an evidence-based intervention) to increase providers' capacity to provide gender-responsive treatment and counseling to men and women on HIV treatment in Uganda. Delivered to HIV providers, this group training adapts evidence-based strategies to reduce gender biases and increase skills to deliver gender-specific and transformative HIV counseling to patients. The implementation strategy will be piloted through a quasi-experimental controlled trial. Clinics will be randomly assigned to either the intervention or control conditions. The trial will assess feasibility and acceptability and explore barriers and facilitators to implementation and future adoption while gathering preliminary evidence on the implementation strategy's effectiveness by comparing changes in patient (N = 240) and provider (N = 80-140) outcomes across intervention and control clinics through 12-month follow-up. Quantitative data will be descriptively analyzed, qualitative data will be analyzed through thematic analysis, and these data will be mixed during the presentation and interpretation of results where appropriate.

DISCUSSION

This pilot intervention trial will gather preliminary evidence on the acceptability, feasibility, and potential effect of a novel implementation strategy to improve men and women's HIV care engagement, with the potential to reduce gender disparities in HIV outcomes.

TRIAL REGISTRATION

Clinicaltrials.gov NCT05178979 , retrospectively registered on January 5, 2022.

Racial and Ethnic Differences in Internal Medicine Residency Assessments

Importance

Previous studies have demonstrated racial and ethnic inequities in medical student assessments, awards, and faculty promotions at academic medical centers. Few data exist about similar racial and ethnic disparities at the level of graduate medical education.

Objective

To examine the association between race and ethnicity and performance assessments among a national cohort of internal medicine residents.

Design, Setting, and Participants

This retrospective cohort study evaluated assessments of performance for 9026 internal medicine residents from the graduating classes of 2016 and 2017 at Accreditation Council of Graduate Medical Education (ACGME)-accredited internal medicine residency programs in the US. Analyses were conducted between July 1, 2020, and June 31, 2022.

Main Outcomes and Measures

The primary outcome was midyear and year-end total ACGME Milestone scores for underrepresented in medicine (URiM [Hispanic only; non-Hispanic American Indian, Alaska Native, or Native Hawaiian/Pacific Islander only; or non-Hispanic Black/African American]) and Asian residents compared with White residents as determined by their Clinical Competency Committees and residency program directors. Differences in scores between Asian and URiM residents compared with White residents were also compared for each of the 6 competency domains as supportive outcomes.

Results

The study cohort included 9026 residents from 305 internal medicine residency programs. Of these residents, 3994 (44.2%) were female, 3258 (36.1%) were Asian, 1216 (13.5%) were URiM, and 4552 (50.4%) were White. In the fully adjusted model, no difference was found in the initial midyear total Milestone scores between URiM and White residents, but there was a difference between Asian and White residents, which favored White residents (mean [SD] difference in scores for Asian residents: -1.27 [0.38]; P < .001). In the second year of training, White residents received increasingly higher scores relative to URiM and Asian residents. These racial disparities peaked in postgraduate year (PGY) 2 (mean [SD] difference in scores for URiM residents, -2.54 [0.38]; P < .001; mean [SD] difference in scores for Asian residents, -1.9 [0.27]; P < .001). By the final year 3 assessment, the gap between White and Asian and URiM residents' scores narrowed, and no racial or ethnic differences were found. Trends in racial and ethnic differences among the 6 competency domains mirrored total Milestone scores, with differences peaking in PGY2 and then decreasing in PGY3 such that parity in assessment was reached in all competency domains by the end of training.

Conclusions and Relevance

In this cohort study, URiM and Asian internal medicine residents received lower ratings on performance assessments than their White peers during the first and second years of training, which may reflect racial bias in assessment. This disparity in assessment may limit opportunities for physicians from minoritized racial and ethnic groups and hinder physician workforce diversity.

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

Objective

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

Methods

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

Results

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

Conclusions

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

Instituting Sexual Orientation and Gender Identity Training and Documentation to Increase Inclusivity at a Pediatric Health System

In this mixed-methods quality improvement project, we implemented and evaluated sexual orientation and gender identity (SOGI) form rollout in the electronic medical record. Families in our gender diversity program completed a baseline survey in 2017 (55/328 responded) and follow-up in 2020 (180/721 responded) to evaluate the frequency of affirmed name and pronoun use in the hospital. Survey feedback informed system-wide inclusivity efforts and training. SOGI was implemented in 2020 after 1,662 providers completed an online training and 11,090 team members completed gender and sexual orientation inclusivity training. We recommend similar trainings for health systems utilizing SOGI.

Classroom Instruction: Medical Students' Attitudes Toward LGBTQI+ Patients

The Association of American Medical Colleges declared it essential that medical students receive instruction on the health needs of lesbian, gay, bisexual, transgender, questioning, and intersex (LGBTQI+) individuals. The integration of LGBTQI+ health and instruction in medical curricula, however, is scant. A pre-post confidential survey study was completed by first-year medical students (N = 103; 85% response rate) in the context of classroom instruction. The California State University Northbridge instrument assessed students' perspectives on LGBTQI+ Patient-Care, Comfort with LGBTQI+ Patient Interactions, Gender and Sexuality, Civil Rights, and LGBTQI+ Education. Post-instruction, students reported a significant increase in understanding of bisexuality (p = .02), being transgender (p = .006), and LGBTQI+ couples' adoption rights (p = .003). The findings support the incorporation of LGBTQI+ instruction into medical curricula and suggest that educators may consider consulting pre-intervention data before teaching LGBTQI+ health content, which would allow material to be tailored toward learner-specific needs.

Ethnicity-related stereotypes and their impacts on medical students: A critical narrative review of health professions education literature

BACKGROUND

Stereotypes are oversimplified beliefs about groups of people. Social psychology concepts and theories describing ethnicity-related stereotypes are well reported in non-medical educational settings. In contrast, the full impact of stereotyping on medical students, and the extent to which they were represented in health professions education (HPE) is less well-described. Using the lens of social psychological theory, this review aimed to describe ethnicity-related stereotypes about medical students portrayed in HPE literature and the impacts of those stereotypes.

METHODS

A critical narrative approach was undertaken. Social psychology concepts and theories were used as a framework through which to review the impacts of ethnicity-related stereotypes on medical students as described in HPE literature. A database search of Ovid MEDLINE, JSTOR, Project Muse, and PsychINFO was conducted to identify both theoretical and empirical articles relating to this topic in the HPE literature. Data was synthesised using thematic analysis, giving particular care to appraise the evidence from perspectives in social psychology.

FINDINGS

In HPE, the experiences and impact of stereotyping on learners from minority ethnic groups was explained by social psychology concepts such as stereotype threat, stereotype reactance, attributional ambiguity, self-fulfilling prophecy, stereotype boost, stereotype lift, and stereotype masking. Stereotype boost and stereotype lift were particularly described among students who identified as White, whereas stereotype threat was described more commonly among students from minority ethnics groups. The impact of stereotyping is not just on assessment, but may be across all teaching and learning activities at medical school.

INTERPRETATION

Social psychology concepts and theories can be used to describe the experience and impact of ethnicity-related stereotypes in HPE. Educators can better support learners from minority ethnic groups by self-reflecting over assumptions about individuals from minority ethnic groups, as well as minimise the impact of stereotyping and bias to create more inclusive learning environments.

Medical students' perceptions of their preparedness to care for LGBT patients in Taiwan: Is medical education keeping up with social progress?

INTRODUCTION

Integrating training on health equity of sexual and gender minorities (SGM) in medical education has been challenging globally despite emphasis on the need for medical students to develop competence to provide adequate care for diverse patient groups. This study elicits Taiwanese medical students' perceptions of their values and preparedness to care for Lesbian, Gay, Bisexual, or Transgender (LGBT) patients using a qualitative approach that considers broader societal changes, and more focused topics such as the provision of relevant training in medical education.

METHODS

Eighty-nine medical students/trainees from two southern Taiwanese medical schools (one public and one private) participated in focus groups (n = 70) and individual interviews (n = 19). Qualitative analysis was conducted using inductive thematic analysis.

RESULTS

Participants (i) expressed wide social acceptance and openness toward LGBT individuals, but were unsure of ways to communicate with LGBT patients; (ii) confirmed that stigmatization and biases might be developed during their training; (iii) recognized gender stereotypes could have negative impacts on clinical reasoning; (iv) considered themselves prepared to care for LGBT patients, yet equated non-discriminatory attitudes to preparedness; (v) acknowledged a lack of relevant professional skills; (vi) implicated curriculum did not address LGBT issues systematically and explicitly.

CONCLUSION

This study has identified the insufficiencies of current medical training and inadequate preparedness of medical students/trainees to provide better care for LGBT patients. It provides insights for medical educators to design and implement effective medical curriculum and training, and faculty development programs to equip medical students/trainees with self-awareness and competencies to more readily provide holistic care for SGM, in keeping up with social progress, and promote health equity for a more diverse patient population.

Strategies For Enhancing Equity, Diversity, and Inclusion in Medical School Admissions–A Canadian Medical School's Journey

Background

Medical schools aim to select and train future physicians representative of and able to serve their diverse population needs. Enhancing equity, diversity, and inclusion (EDI) in admissions processes includes identifying and mitigating barriers for those underrepresented in medicine (URM).

Summary of Innovations

In 2017, Schulich School of Medicine and Dentistry (Western University, Ontario, Canada) critically reviewed its general Admissions pathways for the Doctor of Medicine (MD) program. Till that time, interview invitations were primarily based on academic metrics rather than a holistic review as for its Indigenous MD Admissions pathway. To help diversify the Canadian physician workforce, Schulich Medicine utilized a multipronged approach with five key changes implemented over 2 years into the general MD Admissions pathways: 1. A voluntary applicant diversity survey (race, socioeconomic status, and community size) to examine potential barriers within the Admissions process; 2. Diversification of the admissions committee and evaluator pool with the inclusion of an Equity Representative on the admissions committee; 3. A biosketch for applicants' life experiences; 4. Implicit bias awareness training for Committee members, file reviewers and interviewers; and 5. A specific pathway for applicants with financial, sociocultural, and medical barriers (termed ACCESS pathway). Diversity data before (Class of 2022) vs. after (Class of 2024) these initiatives and of the applicant pool vs. admitted class were examined.

Conclusion

For the Class of 2024, the percentage of admitted racialized students (55.2%), those with socioeconomic challenges (32.3%), and those from remote/rural/small town communities (18.6%) reflected applicant pool demographics (52.8, 29.9, and 17.2%, respectively). Additionally, 5.3% (vs. 5.6% applicant pool) of admitted students had applied through ACCESS. These data suggest that barriers within the admissions process for these URM populations were potentially mitigated by these initiatives. The initiatives broadly improved representation of racialized students, LGBTQ2S+, and those with disability with statistically significant increases in representation of those with socioeconomic challenges (32.3 vs. 19.3%, p = 0.04), and those with language diversity (42.1 vs. 35.0%, p = 0.04). Thus, these changes within the general MD admissions pathways will help diversify the future Canadian physician workforce and inform future initiatives to address health equity and social accountability within Canada.

Digestive Health in Sexual and Gender Minority Populations

It has been over 50 years since the Stonewall Inn Riots in June 1969, a seminal event for the lesbian, gay, bisexual, transgender, queer, intersex, and other sexual and gender-diverse minorities (LGBTQI+, or lesbian, gay, bisexual, transgender, queer, intersex, and everyone else) rights movement. However, sexual and gender minority (SGM) individuals still face discrimination and harassment due to their sexual orientation or gender identity. As such, the National Institute on Minority Health and Health Disparities has identified SGM communities as a "health disparity population." Broadly, there are higher rates of sexually transmitted infections, substance use and abuse, mental health conditions, obesity and eating disorders, certain cancers (breast, cervical, and anorectal), and cardiovascular disease in SGM communities. Transgender patients, especially those of color, are more likely to be uninsured, experience discrimination, and be denied health care than cisgender patients. In addition, SGM individuals have twice the risk of lifetime exposure to emotional, physical, and sexual trauma compared with heterosexuals. It is expected all these factors would negatively affect digestive health as well. This review summarizes the effects of social determinants of health and discrimination on health care access, highlights important digestive diseases to consider in the SGM population, and offers solutions to improve and prioritize the health of these communities. We aim to draw attention to SGM-specific issues that affect gastrointestinal health and spur research that is desperately lacking.