More Than Words: A Vision to Address Bias and Reduce Discrimination in the Health Professions Learning Environment

Different View of the Issue: Seeing Disability Through the Lens of Diversity and Inclusivity in Health Care in the United States

ABSTRACT

Advocacy for diversity, inclusion, and equity within healthcare continues to be an issue of importance and attention nationally. However, definitions of diversity often do not include people with disability. This commentary describes barriers to healthcare utilization experienced by people with disabilities in the United States and presents a rationale to refocus disability through this lens of diversity, equity, and inclusion within the US systems of care. Bringing light to the ongoing challenges and inequities faced by our patients with disability is an essential first step toward improved inclusivity, leading to improved welfare of persons with disability as a whole.

W, A. K. The story so far………- current opinion in the use and applications of interactive storytelling in physiology and clinical education

Physiology and clinical practice are subjects of study which demand integration of multiple sources of systems working knowledge and information on the performance of those systems to come to meaningful conclusions. This is made more complex by the interpretation and actions as a result of this conclusion having direct impact on the sum of the component systems, the human, thereby integrating significant social and psychological considerations into an already complex situation. As higher education educators, it is a significant challenge to provide our learners with training and most importantly, practice, in these knowledge, skills and behaviours in the classroom. There has been a significant interest in recent years in providing active learning opportunities which allow learners to apply subject knowledge to multi-faceted, immersive, continuously evolving stories which reflect a graduate's professional aspirations. This review highlights practices from the literature of storytelling education which the higher education educator can utilise in promoting "meaning making" in the classroom. Here, the case for interactive storytelling in physiology and clinical education is argued, as well as presenting commonly utilised techniques and practices with which educators can embed storytelling into their pedagogy as well as highlighting future directions in this field.

The Dietetics Profession Privilege Scale: Development, Psychometric Testing, and Application Among a Diverse Cohort of Dietetics Professionals

BACKGROUND

Privilege (defined as the unearned advantage or disadvantage experienced by social groups resulting from structural power differences) impacts efforts to create a diverse and inclusive dietetics profession. Yet, no current measures exist to assess and observe privilege, and the relative privilege among dietetics professionals (DPs) is unknown.

OBJECTIVE

The purpose of this study was to develop and validate a scale to measure DP privilege and to use that scale to assess privilege among a sample of DPs in the United States.

DESIGN

The initial scale was developed by the research team and the psychometrics were assessed using a 3-phase cross-sectional study exploring construct, content and face validity, and test-retest reliability.

PARTICIPANTS/SETTING

A survey with content experts (n = 18), cognitive interviewees (n = 12), and a survey of DPs (n = 900) were conducted online and over Zoom during 2021.

STATISTICAL ANALYSES

Exploratory factor analysis, 1-way analysis of variance, Cronbach's α, and descriptive statistics were used to assess the final instrument and identify correlates of privilege.

RESULTS

Findings indicate that the 29-item Dietetic Profession Privilege Scale has good validity and reliability across 6 domains (ie, treatment in training, identity alignment, resource access, cultural access, financial access, and physical access). The mean (SE) privilege score among the current sample of DPs was 45 (10.2) out of 58 points, with the greatest gaps between racial and ethnic groups, where White DPs (n = 540) had a mean (SE) score of 49.7 (0.33), followed by a mean score of 41.0 among Middle Eastern/North African DPs (n = 9); mean score of 40.0 for the Native Hawaiian and Pacific Islander-identifying DP; mean (SE) score of 39.8 (0.93) among DPs with 2 or more racial or ethnic identities, including White (n = 68); mean score of 35.7 among DPs with 2 or more marginalized racial or ethnic identities (n = 6); a mean (SE) score of 35.3 (1.07) among Black or African American DPs (n = 51); a mean (SE) score of 34.3 (0.93) among Asian DPs (n = 67); a mean (SE) score of 33.4 (0.91) among Latino, Hispanic, and Chicano DPs (n = 71); and a mean (SE) 29.4 (3.42) among American Indian and Alaskan Native DPs (P < .001 for all racial and ethnic groups in which n > 10; SE not indicated for groups when n < 10). DPs with dominant group identities were found to have statistically higher privilege scores than their peers with marginalized identities in several areas, including race, gender, sexual orientation, income, socioeconomic status, neurodivergence, and ableness, and scored higher on the privilege scale than their peers with marginalized identities.

CONCLUSIONS

The Dietetics Profession Privilege Scale is a valid and reliable scale that demonstrates the ability to distinguish differences in privilege between DPs in the interest of reducing bias and achieving inclusion, diversity, equity, and access with the profession.

Discrimination in Medical Settings across Populations: Evidence From the All of Us Research Program

INTRODUCTION

Discrimination in medical settings (DMS) contributes to healthcare disparities in the United States, but few studies have determined the extent of DMS in a large national sample and across different populations. This study estimated the national prevalence of DMS and described demographic and health-related characteristics associated with experiencing DMS in seven different situations.

METHODS

Survey data from 41,875 adults participating in the All of Us Research Program collected in 2021-2022 and logistic regression were used to examine the association between sociodemographic and health-related characteristics and self-reported DMS among adults engaged with a healthcare provider within the past 12 months. Statistical analysis was performed in 2023-2024.

RESULTS

About 36.89% of adults reported having experienced at least one DMS situation. Adults with relative social and medical disadvantages had higher prevalence of experiencing DMS. Compared to their counterparts, respondents with higher odds of experiencing DMS in at least one situation identified as female, non-Hispanic Black, having at least some college, living in the South, renter, having other living arrangement, being publicly insured, not having a usual source of care, having multiple chronic conditions, having any disability, and reporting fair or poor health, p<0.05.

CONCLUSIONS

The findings indicate a high prevalence of DMS, particularly among some population groups. Characterizing DMS may be a valuable tool for identifying populations at risk within the healthcare system and optimizing the overall patient care experience. Implementing relevant policies remains an essential strategy for mitigating the prevalence of DMS and reducing healthcare disparities.

Psychological safety in medical education: A scoping review and synthesis of the literature

PURPOSE

Psychological safety (PS) is the belief that the environment is safe for risk taking. Available data point to a lack of PS in medical education. Based on literature in other fields, PS in clinical learning environments (CLEs) could support trainee well-being, belonging, and learning. However, the literature on PS in medical education has not been broadly assessed.

MATERIALS AND METHODS

In 2020, authors searched PubMed, Web of Science, CINAHL, Scopus, ERIC, PsycInfo, and JSTOR for articles published prior to January 2020. Authors screened all search results for eligibility using specific criteria. Data were extracted and thematic analysis performed.

RESULTS

Fifty-two articles met criteria. The majority focused on graduate medical education (45%), and 42% of studies took place within a CLE. Articles addressed organizational and team level constructs (58%), with fewer descriptions of specific behaviors of team members that promote or hinder safety. The impacts of safe environments for trainees and patients are areas in need of more exploration.

DISCUSSION

Future research should focus on defining specific organizational and interpersonal leader behaviors that promote PS, seek to understand how PS is determined by individual trainees, and measure the impact of PS on learners, learning, and patient care outcomes.

Understanding the Role of Urology Practice Organization and Racial Composition in Prostate Cancer Treatment Disparities

PURPOSE

Black men have a higher risk of prostate cancer diagnosis and mortality but are less likely to receive definitive treatment. The impact of structural aspects on treatment is unknown but may lead to actionable insights to mitigate disparities. We sought to examine the associations between urology practice organization and racial composition and treatment patterns for Medicare beneficiaries with incident prostate cancer.

METHODS

Using a 20% sample of national Medicare data, we identified beneficiaries diagnosed with prostate cancer between January 2010 and December 2015 and followed them through 2016. We linked urologists to their practices with tax identification numbers. We then linked patients to practices on the basis of their primary urologist. We grouped practices into quartiles on the basis of their proportion of Black patients. We used multilevel mixed-effects models to identify treatment associations.

RESULTS

We identified 54,443 patients with incident prostate cancer associated with 4,194 practices. Most patients were White (87%), and 9% were Black. We found wide variation in racial practice composition and practice segregation. Patients in practices with the highest proportion of Black patients had the lowest socioeconomic status (43.1%), highest comorbidity (9.9% with comorbidity score ≥ 3), and earlier age at prostate cancer diagnosis (33.5% age 66-69 years; P < .01). Black patients had lower odds of definitive therapy (adjusted odds ratio, 0.87; 95% CI, 0.81 to 0.93) and underwent less treatment than White patients in every practice context. Black patients in practices with higher proportions of Black patients had higher treatment rates than Black patients in practices with lower proportions. Black patients had lower predicted probability of treatment (66%) than White patients (69%; P < .05).

CONCLUSION

Despite Medicare coverage, we found less definitive treatment among Black beneficiaries consistent with ongoing prostate cancer treatment disparities. Our findings are reflective of the adverse effects of practice segregation and structural racism, highlighting the need for multilevel interventions.

Black Physicians' Experiences with Anti-Black Racism in Healthcare Systems Explored Through An Attraction-Selection-Attrition Lens

Anti-Black racism is a specific form of racism directed at Black people. In healthcare, there are poignant examples of anti-Black racism in the recruitment, selection, and retention stages of the job cycle. Research shows that anti-Black racism is associated with inequitable work outcomes and the under-representation of Black physicians. However, empirical findings are scattered with no organizing framework to consolidate these findings. To add to the literature, in this paper we present the attraction-selection-attrition (ASA) model (Schneider, 1987) as an organizing framework to discuss Black physicians' experiences with anti-Black racism and discrimination throughout their careers. We draw from previous literature to highlight specific experiences of Black physicians at each stage of the job cycle (i.e., attraction, selection, retention), and we offer considerations on how practitioners can mitigate anti-Black racism throughout the job cycle. In the wake of COVID-19 and highly publicized social justice movements, healthcare systems are seeking ways to increase the recruitment, selection, and retention of Black physicians to ensure health equity. We believe this guide will be valuable to practitioners, leaders, researchers, and program directions seeking to advance diversity, equity, and inclusion of Black physicians in their healthcare systems. We conclude by providing practical implications and directions for future research.

Diversity, equity, and inclusion: one model to move from commitment to action in medical education

The summer of 2020 riveted the attention of our nation with a sense of urgency to address structural racism. Cities declared racism a public health crisis, and organizations called for increased awareness of persistent historic racial inequities and advocacy for change. In medical education, students and institutional leaders felt compelled to transition from passive advocacy to energetic action in order to build a culture of anti-racism. In our institution, we applied J Mierke and V. Williamson's 6-step framework to achieve organizational culture change which is as follows: 1. Identify the catalyst for change; 2. Strategically plan for successful change; 3. Engage and empower organizational members; 4. Cultivate leaders at all levels; 5. Foster innovation, creativity, and risk-taking; 6. Monitor progress, measure success, and celebrate (even the small changes) along the way. In addition, we noted two key considerations for the success of the process: A. Transparency in communication, and B. Flexibility and adjustment to emerging situations. We share our approach using this framework which we believe is generalizable to other organizations. We draw from literature on organizational psychology and lastly call for the continuation and sustainability of the work that will continue to build a diverse, equitable, inclusive, antiracist and vibrant education community.

What Happened and Why: Responding to Racism, Discrimination, and Microaggressions in the Clinical Learning Environment

INTRODUCTION

Within clinical learning environments, medical students are uniquely faced with power differentials that make acts of racism, discrimination, and microaggressions (RDM) challenging to address. Experiences of microaggressions and mistreatment are correlated with higher rates of positive depression screening and lower satisfaction with medical training. We developed a curriculum for medical students beginning clerkship rotations to promote the recognition of and response to RDM.

METHODS

Guided by generalized and targeted needs assessments, we created a case-based curriculum to practice communication responses to address RDM. The communication framework, a 6Ds approach, was developed through adaptation and expansion of established and previously learned communication upstander frameworks. Cases were collected through volunteer submission and revised to maintain anonymity. Faculty and senior medical students cofacilitated the small-group sessions. During the sessions, students reviewed the communication framework, explored their natural response strategies, and practiced all response strategies.

RESULTS

Of 196 workshop participants, 152 (78%) completed the evaluation surveys. Pre- and postsession survey cohort comparison demonstrated a significant increase in students' awareness of instances of RDM (from 34% to 46%), knowledge of communication strategies to mitigate RDM (presession M = 3.4, postsession M = 4.6, p < .01), and confidence to address RDM (presession M = 3.0, postsession M = 4.4, p < .01).

DISCUSSION

Students gained valuable communication skills from interactive sessions addressing RDM using empathy, reflection, and relatability. The workshop empowered students to feel prepared to enter professional teams and effectively mitigate harmful discourse.

Implementing and Assessing a Resident Diversity Council to Address the Need for a Diverse Clinical Workforce

Importance

Minoritized racial and ethnic groups remain underrepresented in medicine (UIM) compared with the general population. Although many residency programs want to train a diverse group of individuals, methods for implementation are not fully established.

Objective

To describe the implementation and restructuring of the Boston Combined Residency Program (BCRP) Diversity Council and evaluate the association between restructuring the BCRP Diversity Council and the number of UIM interns.

Design, Setting, and Participants

A retrospective cohort study was conducted on a large academic pediatric residency program at Boston Children's Hospital and Boston Medical Center. Interns who matched in the BCRP from March 17, 2011, to March 18, 2021, were included. Interns who matched in an affiliated medicine-pediatrics residency were excluded because they are not universally exposed to the same recruitment efforts as individuals in the other BCRP tracks.

Exposure

Because the BCRP Diversity Council was restructured in 2016, 2011-2016 was defined as the prerestructuring era and 2017-2021 as the postrestructuring era.

Main Outcomes and Measures

The primary outcome was the proportion of interns who self-identified as UIM.

Results

A total of 516 BCRP interns from 2011 to 2021 were included. A total of 62 individuals (12.0%) identified as racial and ethnic identities UIM (ie, American Indian/Alaska Native, Black/African American, Hispanic/Latino, and Native Hawaiian/Pacific Islander). During the 6-year prerestructuring Diversity Council era, 27 of the 275 BCRP interns (9.8%) were UIM; 35 of 241 BCRP interns (14.5%) were UIM during the 5-year restructured Diversity Council era (χ2 P = .10).

Conclusions and Relevance

In this cohort study, the number of UIM interns was higher after the BCRP Diversity Council was restructured, although the difference was not statistically significant. As the magnitude of the Diversity Council's influence is multidimensional, perhaps studying additional aspects would have better captured its impact. The BCRP Diversity Council has expanded innovative recruitment initiatives, supported efforts to improve the resident experience, and collaborated with the residency and institutional leadership to promote an inclusive and antiracist learning environment.

Medical Schools as Racialized Organizations: How Race-Neutral Structures Sustain Racial Inequality in Medical Education-a Narrative Review

In 2021, The American Association of Medical Colleges released a framework addressing structural racism in academic medicine, following the significant, nationwide Movement for Black Lives. The first step of this framework is to "begin self-reflection and educating ourselves." Indeed, ample evidence shows that medical schools have a long history of racially exclusionary practices. Drawing on racialized organizations theory from the field of sociology, we compile and examine scholarship on the role of race and racism in medical training, focusing on disparities in educational and career outcomes, experiences along racial lines in medical training, and long-term implications. From the entrance into medical school through the residency application process, organizational factors such as reliance on standardized tests to predict future success, a hostile learning climate, and racially biased performance metrics negatively impact the careers of trainees of color, particularly those underrepresented in medicine (URiM). Indeed, in addition to structural biases associated with otherwise "objective" metrics, there are racial disparities across subjective outcomes such as the language used in medical trainees' performance evaluations, even when adjusting for grades and board exam scores. These disadvantages contribute to URIM trainees' lower odds of matching, steering into less competitive and lucrative specialties, and burnout and attrition from academic careers. Additionally, hostile racial climates and less diverse medical schools negatively influence White trainees' interest in practicing in underserved communities, disproportionally racial and ethnic minorities. Trainees' mental health suffers along the way, as do medical schools' recruitment, retention, diversity, and inclusion efforts. Evidence shows that seemingly race-neutral processes and structures within medical education, in conjunction with individuals' biases and interpersonal discrimination, may reproduce and sustain racial inequality among medical trainees. Medical schools whose goals include training a more diverse physician workforce towards addressing racial health disparities require a new playbook.

Medical Students' Socialization Tactics When Entering a New Clinical Clerkship: A Mixed Methods Study of Proactivity

PURPOSE

Socialization into clinical clerkships is difficult in part due to ambiguity around students' new roles and expected behaviors. Being proactive reduces ambiguity and is essential to socialization. Proactive behavior can be taught and goes beyond having a proactive personality. Among students entering new undergraduate clinical clerkships, this study aimed to investigate (1) reported proactive behaviors and their association with social integration and (2) enabling and inhibiting factors for proactive behavior.

METHOD

This study was conducted at the 5-year MBBS program at Western Sydney University during academic year 2019-2020. Using a convergent mixed methods approach, survey and interview data from third-, fourth-, and fifth-year students were collected. Surveys explored 5 proactive behaviors: feedback seeking, information seeking, task negotiation, positive framing, and relationship building. Interviews elicited descriptions of how students described their proactivity and what influenced students to be proactive when entering a new clerkship. Data were integrated using the following the thread and mixed methods matrix techniques.

RESULTS

Students exhibited all 5 proactive behaviors. Survey data showed positive framing and task negotiation had the highest and lowest scores, respectively. Only positive framing correlated significantly with social integration scores (r = 0.27; P < .01), but this contrasted to interviews, in which students described how other proactive behaviors also led to social integration. Proactive behavior scores decreased across academic years. Integrated data showed 3 linked antecedents to whether students exhibited proactive behavior: feeling capable of being proactive, individual intention to be proactive, and the immediate environment and system-level factors.

CONCLUSIONS

Students who framed the experience positively were more likely to report increased social integration. Initiating task negotiation was challenging for most students. The authors propose a conceptual model for proactivity and social integration to support socialization and learning during clinical transitions for future research and interventional design.

Physician Identification Badges: A Multispecialty Quality Improvement Study to Address Professional Misidentification and Bias

OBJECTIVE

To evaluate whether providing resident physicians with "DOCTOR" role identification badges would impact perceptions of bias in the workforce and alter misidentification rates.

PARTICIPANTS AND METHODS

Between October 2019 and December 2019, we surveyed 341 resident physicians in the anesthesiology, dermatology, internal medicine, neurologic surgery, otorhinolaryngology, and urology departments at Mayo Clinic in Rochester, Minnesota, before and after an 8-week intervention of providing "DOCTOR" role identification badges. Differences between paired preintervention and postintervention survey answers were measured, with a focus on the frequency of experiencing perceived bias and role misidentification (significance level, α=.01). Free-text comments were also compared.

RESULTS

Of the 159 residents who returned both the before and after surveys (survey response rate, 46.6% [159 of 341]), 128 (80.5%) wore the "DOCTOR" badge. After the intervention, residents who wore the badges were statistically significantly less likely to report role misidentification at least once a week from patients, nonphysician team members, and other physicians (50.8% [65] preintervention vs 10.2% [13] postintervention; 35.9% [46] vs 8.6% [11]; 18.0% [23] vs 3.9% [5], respectively; all P<.001). The 66 female residents reported statistically significantly fewer episodes of gender bias (65.2% [43] vs 31.8% [21]; P<.001). The 13 residents who identified as underrepresented in medicine reported statistically significantly less misidentification from patients (84.6% [11] vs 23.1% [3]; P=.008); although not a statistically significant difference, the 13 residents identifying as underrepresented in medicine also reported less misidentification with nonphysician team members (46.2% [6] vs 15.4% [2]; P=.13).

CONCLUSION

Residents reported decreased role misidentification after use of a role identification badge, most prominently improved among women. Decreasing workplace bias is essential in efforts to improve both diversity and inclusion efforts in training programs.

Eliminating Explicit and Implicit Biases in Health Care: Evidence and Research Needs

Health care providers hold negative explicit and implicit biases against marginalized groups of people such as racial and ethnic minoritized populations. These biases permeate the health care system and affect patients via patient–clinician communication, clinical decision making, and institutionalized practices. Addressing bias remains a fundamental professional responsibility of those accountable for the health and wellness of our populations. Current interventions include instruction on the existence and harmful role of bias in perpetuating health disparities, as well as skills training for the management of bias. These interventions can raise awareness of provider bias and engage health care providers in establishing egalitarian goals for care delivery, but these changes are not sustained, and the interventions have not demonstrated change in behavior in the clinical or learning environment. Unfortunately, the efficacy of these interventions may be hampered by health care providers’ work and learning environments, which are rife with discriminatory practices that sustain the very biases US health care professions are seeking to diminish. We offer a conceptual model demonstrating that provider-level implicit bias interventions should be accompanied by interventions that systemically change structures inside and outside the health care system if the country is to succeed in influencing biases and reducing health inequities.

Faculty Recruitment, Retention, and Representation in Leadership: An Evidence-Based Guide to Best Practices for Diversity, Equity, and Inclusion from the Council of Residency Directors in Emergency Medicine

Improving the recruitment, retention, and leadership advancement of faculty who are under-represented in medicine is a priority at many academic institutions to ensure excellence in patient care, research, and health equity. Here we provide a critical review of the literature and offer evidence-based guidelines for faculty recruitment, retention, and representation in leadership. Recommendations for recruitment include targeted recruitment to expand the candidate pool with diverse candidates, holistic review of applications, and incentivizing stakeholders for success with diversity efforts. Retention efforts should establish a culture of inclusivity, promote faculty development, and evaluate for biases in the promotion and tenure process. We believe this guide will be valuable for all leaders and faculty members seeking to advance diversity, equity, and inclusion in their institutions.

Towards equitable learning environments for medical education: Bias and the intersection of social identities

CONTEXT

Medical educators are increasingly paying attention to how bias creates inequities that affect learners across the medical education continuum. Such bias arises from learners' social identities. However, studies examining bias and social identities in medical education tend to focus on one identity at a time, even though multiple identities often interact to shape individuals' experiences.

METHODS

This article examines prior studies on bias and social identity in medical education, focusing on three social identities that commonly elicit bias: race, gender and profession. By applying the lens of intersectionality, we aimed to generate new insights into intergroup relations and identify strategies that may be employed to mitigate bias and inequities across all social identities.

RESULTS

Although different social identities can be more or less salient at different stages of medical training, they intersect and impact learners' experiences. Bias towards racial and gender identities affect learners' ability to reach different stages of medical education and influence the specialties they train in. Bias also makes it difficult for learners to develop their professional identities as they are not perceived as legitimate members of their professional groups, which influences interprofessional relations. To mitigate bias across all identities, three main sets of strategies can be adopted. These strategies include equipping individuals with skills to reflect upon their own and others' social identities; fostering in-group cohesion in ways that recognise intersecting social identities and challenges stereotypes through mentorship; and addressing intergroup boundaries through promotion of allyship, team reflexivity and conflict management.

CONCLUSIONS

Examining how different social identities intersect and lead to bias and inequities in medical education provides insights into ways to address these problems. This article proposes a vision for how existing strategies to mitigate bias towards different social identities may be combined to embrace intersectionality and develop equitable learning environments for all.

Understanding Healthcare Students' Experiences of Racial Bias: A Narrative Review of the Role of Implicit Bias and Potential Interventions in Educational Settings

Implicit racial bias is a persistent and pervasive challenge within healthcare education and training settings. A recent systematic review reported that 84% of included studies (31 out of 37) showed evidence of slight to strong pro-white or light skin tone bias amongst healthcare students and professionals. However, there remains a need to improve understanding about its impact on healthcare students and how they can be better supported. This narrative review provides an overview of current evidence regarding the role of implicit racial bias within healthcare education, considering trends, factors that contribute to bias, and possible interventions. Current evidence suggests that biases held by students remain consistent and may increase during healthcare education. Sources that contribute to the formation and maintenance of implicit racial bias include peers, educators, the curriculum, and placements within healthcare settings. Experiences of implicit racial bias can lead to psychosomatic symptoms, high attrition rates, and reduced diversity within the healthcare workforce. Interventions to address implicit racial bias include an organizational commitment to reducing bias in hiring, retention, and promotion processes, and by addressing misrepresentation of race in the curriculum. We conclude that future research should identify, discuss, and critically reflect on how implicit racial biases are enacted and sustained through the hidden curriculum and can have detrimental consequences for racial and ethnic minority healthcare students.

New Horizons-Addressing Healthcare Disparities in Endocrine Disease: Bias, Science, and Patient Care

Unacceptable healthcare disparities in endocrine disease have persisted for decades, and 2021 presents a difficult evolving environment. The COVID-19 pandemic has highlighted the gross structural inequities that drive health disparities, and antiracism demonstrations remind us that the struggle for human rights continues. Increased public awareness and discussion of disparities present an urgent opportunity to advance health equity. However, it is more complicated to change the behavior of individuals and reform systems because societies are polarized into different factions that increasingly believe, accept, and live different realities. To reduce health disparities, clinicians must (1) truly commit to advancing health equity and intentionally act to reduce health disparities; (2) create a culture of equity by looking inwards for personal bias and outwards for the systemic biases built into their everyday work processes; (3) implement practical individual, organizational, and community interventions that address the root causes of the disparities; and (4) consider their roles in addressing social determinants of health and influencing healthcare payment policy to advance health equity. To care for diverse populations in 2021, clinicians must have self-insight and true understanding of heterogeneous patients, knowledge of evidence-based interventions, ability to adapt messaging and approaches, and facility with systems change and advocacy. Advancing health equity requires both science and art; evidence-based roadmaps and stories that guide the journey to better outcomes, judgment that informs how to change the behavior of patients, providers, communities, organizations, and policymakers, and passion and a moral mission to serve humanity.

Biopsychosocial factors related to transition among adolescents and young adults with sickle cell disease: A systematic review

It is critical to support adolescents and young adults (AYAs) with sickle cell disease (SCD) during transition to adult healthcare. We provide a systematic review of literature related to biopsychosocial influences on transition among AYAs with SCD. Data sources included studies published between January 2010 and May 2020. Forty-four studies were included. Biopsychosocial factors related to improved transition outcomes included older AYA age, greater disease severity, intact neurocognitive functioning, and greater pain coping skills. Financial and insurance barriers were noted. The importance of cultural considerations and provider communication were noted across two qualitative studies. Ten studies assessed efficacy of transition interventions, with 80 % resulting in improvements; however, retention in programs was low and gaps in knowledge and skills remained. Incorporation of early, ongoing assessments of transition readiness and barriers into culturally-tailored interventions aimed at improving transition outcomes is recommended. Examination of longitudinal relationships and interactions across biopsychosocial influences is needed.

Planning for diverse, equitable, inclusive research in health professions education: An integral thread in the ARMED MedEd research course

Racism in medicine affects patients, trainees, and practitioners and contributes to health care inequities. An effective strategy to actively oppose the structural racism ingrained in the fabric of medicine is to intentionally and systematically address diversity, equity, and inclusion (DEI) in medical education and research. As part of ARMED MedEd, a new longitudinal cohort course in advanced research methods in medical education, sponsored by the Society for Academic Emergency Medicine, the leadership team deliberately included a nested DEI curriculum. The goal of the DEI curriculum is to reduce bias in development, recruitment, and implementation of education research studies to promote equity and inclusion in medical education, research, and ultimately, patient care. A team of medical educators with expertise in DEI developed curricular elements focusing on DEI in education research. The two major components are a didactic curriculum (including implicit bias training) to teach researchers to consider equity as they design studies and a consultative service to refine research protocols to address lingering unintended bias. A dedicated focus on DEI can be incorporated into an advanced education research methodology course to raise awareness and provide tools to avoid bias in research design and implementation of interventions. Over time, the network of education researchers who are trained in DEI awareness will grow and provide equitable offerings to their learners to mitigate health inequities.

Improving Diversity in Pediatric Residency Selection: Using an Equity Framework to Implement Holistic Review

BACKGROUND

Many programs struggle to recruit, select, and match a diverse class of residents, and the most effective strategies for holistic review of applications to enhance diversity are not clear.

OBJECTIVE

We determined if holistic pediatric residency application review guided by frameworks that assess for bias along structural, interpersonal, and individual levels would increase the number of matched residents from racial and ethnic groups that are underrepresented in medicine (UiM).

METHODS

Between 2017 and 2020, University of California San Francisco Pediatrics Department identified structural, interpersonal, and individual biases in existing selection processes and developed mitigation strategies in each area. Interventions included creating a shared mental model of desirable qualities in residents, employing a new scoring rubric, intentional inclusion of UiM faculty and trainees in the selection process, and requiring anti-bias training for everyone involved with recruitment and selection.

RESULTS

Since implementing these changes, the percentage of entering interns who self-identify as UIM increased from 11% in 2015 to 45% (OR 6.8, P = .008) in 2019 and to 35% (OR 4.6, P = .035) in 2020.

CONCLUSIONS

Using an equity framework to guide implementation of a pediatric residency program's holistic review of applications increased the numbers of matched UiM residents over a 3-year period.

Addressing Bias and Reducing Discrimination: The Professional Responsibility of Health Care Providers

The prevalence of harmful bias and discrimination within the health professions is staggering. Moreover, literature consistently demonstrates their persistence and their negative impact on patient care. Several professional codes of conduct for health professionals highlight the importance of addressing these forces in practice. However, despite this, these forces are often discussed as tangential within health professions curricula. This paper examines the prevalence of bias and discrimination, its effects on patient care and health professions trainees, and reviews the historical context of societal bias and discrimination within the health professions institution. The authors argue that addressing harmful bias and discrimination is the professional responsibility of every provider and essential to effective and equitable care.