The Clarion Call of the COVID-19 Pandemic: How Medical Education Can Mitigate Racial and Ethnic Disparities

Clinical Practice Guideline: Age-Related Hearing Loss

OBJECTIVE

Age-related hearing loss (ARHL) is a prevalent but often underdiagnosed and undertreated condition among individuals aged 50 and above. It is associated with various sociodemographic factors and health risks including dementia, depression, cardiovascular disease, and falls. While the causes of ARHL and its downstream effects are well defined, there is a lack of priority placed by clinicians as well as guidance regarding the identification, education, and management of this condition.

PURPOSE

The purpose of this clinical practice guideline is to identify quality improvement opportunities and provide clinicians trustworthy, evidence-based recommendations regarding the identification and management of ARHL. These opportunities are communicated through clear actionable statements with explanation of the support in the literature, evaluation of the quality of the evidence, and recommendations on implementation. The target patients for the guideline are any individuals aged 50 years and older. The target audience is all clinicians in all care settings. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group (GDG). It is not intended to be a comprehensive, general guide regarding the management of ARHL. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients.

ACTION STATEMENTS

The GDG made strong recommendations for the following key action statements (KASs): (KAS 4) If screening suggests hearing loss, clinicians should obtain or refer to a clinician who can obtain an audiogram. (KAS 8) Clinicians should offer, or refer to a clinician who can offer, appropriately fit amplification to patients with ARHL. (KAS 9) Clinicians should refer patients for an evaluation of cochlear implantation candidacy when patients have appropriately fit amplification and persistent hearing difficulty with poor speech understanding. The GDG made recommendations for the following KASs: (KAS 1) Clinicians should screen patients aged 50 years and older for hearing loss at the time of a health care encounter. (KAS 2) If screening suggests hearing loss, clinicians should examine the ear canal and tympanic membrane with otoscopy or refer to a clinician who can examine the ears for cerumen impaction, infection, or other abnormalities. (KAS 3) If screening suggests hearing loss, clinicians should identify sociodemographic factors and patient preferences that influence access to and utilization of hearing health care. (KAS 5) Clinicians should evaluate and treat or refer to a clinician who can evaluate and treat patients with significant asymmetric hearing loss, conductive or mixed hearing loss, or poor word recognition on diagnostic testing. (KAS 6) Clinicians should educate and counsel patients with hearing loss and their family/care partner(s) about the impact of hearing loss on their communication, safety, function, cognition, and quality of life (QOL). (KAS 7) Clinicians should counsel patients with hearing loss on communication strategies and assistive listening devices. (KAS 10) For patients with hearing loss, clinicians should assess if communication goals have been met and if there has been improvement in hearing-related QOL at a subsequent health care encounter or within 1 year. The GDG offered the following KAS as an option: (KAS 11) Clinicians should assess hearing at least every 3 years in patients with known hearing loss or with reported concern for changes in hearing.

Assisting primary care teams and patients in a culturally diverse periphery: impact on medical students' future career choices

BACKGROUND

Medical students can assist in reducing healthcare disparities and promote health equity by engaging with rural communities and gaining insights into their unique healthcare needs. A two-arm student-delivered program was designed and implemented during COVID-19 in a social-geographic peripheral area to assist clinics with complex chronic and/or socially disadvantaged patients and improve preventive behavior in townships through home visits delivering community kits.

METHODS

We conducted a pre-post design study which included weekly structured medical student reports and monthly structured telephone interviews with clinic directors and municipal partners. Students completed pre-post program survey on their knowledge, skills, and capabilities to address chronic patients from diverse cultural backgrounds (n = 73). The Wilcoxon-Signed-Rank test for related samples was used to determine differences.

RESULTS

Following the program, the knowledge and awareness levels of students about working in the community (P < 0.001) and their knowledge of common chronic diseases were significantly improved (Mean Difference (MD) = 0.31; p < 0.001). The program significantly increased students' interest to integrate into community care alongside a hospital (P = 0.012). Thematic analysis of student reports revealed improved insight into the role of primary care. Clinic directors (90%) were highly satisfied and reported that students became an integral part of the clinics' teams.

CONCLUSIONS

Integrating medical students into the community through primary-care clinics and home visits in diverse communities, exposed students to the interwoven effect of clinical and social determinants on health and improve their knowledge of common chronic diseases. Participation in the program encouraged students to consider a career in community care.

Readiness of Medical Students to Care for Diverse Patients: A Validated Assessment of Cross-Cultural Preparedness, Skills, and Curriculum

Introduction

Effective cross-cultural care is foundational for mitigating health inequities and providing high-quality care to diverse populations. However, medical school teaching practices vary widely, and learners have limited opportunities to develop these critical skills. To understand the current state of cross-cultural education and to identify potential opportunities for improvement, we disseminated a validated survey instrument among medical students at a single institution.

Methods

Learners across 4 years of medical school participated in the cross-cultural care assessment, using a tool previously validated with resident physicians and modified for medical students. The survey assessed medical student perspectives on (1) preparedness, (2) skillfulness, and (3) educational curriculum and learning environment. Cross-sectional data were analyzed by class year, comparing trends between school years.

Results

Of 700 possible survey responses, we received 260 (37% response rate). Fourth-year students had significantly higher scores than first-year students (p<0.05) for 7 of 12 preparedness items and 4 of 9 skillfulness items. Less than 50% of students indicated readiness to deliver cross-cultural care by their fourth year in 9 of 12 preparedness items and 6 of 9 skillfulness items. Respondents identified inadequate cross-cultural education as the primary barrier.

Discussion

Medical students reported a lack of readiness to provide cross-cultural care, with self-assessed deficiencies persisting through the fourth year of medical school. Medical educators can use data from the cross-cultural care survey to longitudinally assess students and enhance curricular exposures where deficiencies exist. Optimizing cross-cultural education has the potential to improve the learning environment and overall patient care.

Allyship to Advance Diversity, Equity, and Inclusion in Otolaryngology: What We Can All Do

Purpose of review

To summarize the current literature on allyship, providing a historical perspective, concept analysis, and practical steps to advance equity, diversity, and inclusion. This review also provides evidence-based tools to foster allyship and identifies potential pitfalls.

Recent findings

Allies in healthcare advocate for inclusive and equitable practices that benefit patients, coworkers, and learners. Allyship requires working in solidarity with individuals from underrepresented or historically marginalized groups to promote a sense of belonging and opportunity. New technologies present possibilities and perils in paving the pathway to diversity.

Summary

Unlocking the power of allyship requires that allies confront unconscious biases, engage in self-reflection, and act as effective partners. Using an allyship toolbox, allies can foster psychological safety in personal and professional spaces while avoiding missteps. Allyship incorporates goals, metrics, and transparent data reporting to promote accountability and to sustain improvements. Implementing these allyship strategies in solidarity holds promise for increasing diversity and inclusion in the specialty.

Patient Safety/Quality Improvement Primer, Part IV: Psychological Safety-Drivers to Outcomes and Well-being

Psychological safety is the concept that an individual feels comfortable asking questions, voicing ideas or concerns, and taking risks without undue fear of humiliation or criticism. In health care, psychological safety is associated with improved patient safety outcomes, increased clinician engagement, and greater creativity. A culture of psychological safety is imperative for physician well-being and satisfaction, which in turn directly affect delivery of care. For health care professionals, psychological safety creates an environment conducive to trust and openness, enabling the team to focus on high-quality care. In contrast, unprofessional behavior reduces psychological safety and threatens the culture of the organization. This patient safety/quality improvement primer considers the barriers and facilitators to psychological safety in health care; outlines principles for creating a psychologically safe environment; and presents strategies for managing conflict, microaggressions, and lapses in professionalism. Individuals and organizations share the responsibility of promoting psychological safety through proactive policies, conflict management, interventions for microaggressions, and cultivation of emotional intelligence.

The Current State of Antiracism Curricula in Undergraduate and Graduate Medical Education: A Qualitative Study of US Academic Health Centers

PURPOSE

We undertook a study to evaluate the current state of pedagogy on antiracism, including barriers to implementation and strengths of existing curricula, in undergraduate medical education (UME) and graduate medical education (GME) programs in US academic health centers.

METHODS

We conducted a cross-sectional study with an exploratory qualitative approach using semistructured interviews. Participants were leaders of UME and GME programs at 5 institutions participating in the Academic Units for Primary Care Training and Enhancement program and 6 affiliated sites from November 2021 to April 2022.

RESULTS

A total of 29 program leaders from the 11 academic health centers participated in this study. Three participants from 2 institutions reported the implementation of robust, intentional, and longitudinal antiracism curricula. Nine participants from 7 institutions described race and antiracism-related topics integrated into health equity curricula. Only 9 participants reported having "adequately trained" faculty. Participants mentioned individual, systemic, and structural barriers to implementing antiracism-related training in medical education such as institutional inertia and insufficient resources. Fear related to introducing an antiracism curriculum and undervaluing of this curriculum relative to other content were identified. Through learners and faculty feedback, antiracism content was evaluated and included in UME and GME curricula. Most participants identified learners as a stronger voice for transformation than faculty; antiracism content was mainly included in health equity curricula.

CONCLUSIONS

Inclusion of antiracism in medical education requires intentional training, focused institutional policies, enhanced foundational awareness of the impact of racism on patients and communities, and changes at the level of institutions and accreditation bodies.

The CTSA Diversity, Equity, Inclusion, and Accessibility (DEIA) Task Force's recommendations for the CTSA program consortium

The Clinical and Translational Science Award (CTSA) Program recognizes that advancing diversity, equity, inclusion, and accessibility (DEIA) requires moving beyond statements of commitment to transformative actions. In 2021, the CTSA Program created a Task Force (TF) to initiate work in support of structural and transformational initiatives that advance DEIA for the consortium and its individual hubs. We describe the process of forming the expertise-driven (DEIA) TF and our activities to date. We 1) developed and adopted the DEIA Learning Systems Framework to guide our approach; 2) defined a set of recommendations across four focus areas (Institutional; Programmatic; Community-Centered; and Social, Cultural, Environmental); and 3) designed and disseminated a survey to capture the CTSA Program's baseline demographic, community, infrastructural, and leadership diversity. The CTSA Consortium also elevated the TF to a standing Committee to extend our understanding, development, and implementation of DEIA approaches to translational and clinical science. These initial steps provide a foundation for collectively fostering environment that support DEIA across the research continuum.

Amplifying patient voices amid pandemic: Perspectives on tracheostomy care, communication, and connection

OBJECTIVE

To investigate perspectives of patients, family members, caregivers (PFC), and healthcare professionals (HCP) on tracheostomy care during the COVID-19 pandemic.

METHODS

The cross-sectional survey investigating barriers and facilitators to tracheostomy care was collaboratively developed by patients, family members, nurses, speech-language pathologists, respiratory care practitioners, physicians, and surgeons. The survey was distributed to the Global Tracheostomy Collaborative's learning community, and responses were analyzed.

RESULTS

Survey respondents (n = 191) from 17 countries included individuals with a tracheostomy (85 [45 %]), families/caregivers (43 [22 %]), and diverse HCP (63 [33.0 %]). Overall, 94 % of respondents reported concern that patients with tracheostomy were at increased risk of critical illness from SARS-CoV-2 infection and COVID-19; 93 % reported fear or anxiety. With respect to prioritization of care, 38 % of PFC versus 16 % of HCP reported concern that patients with tracheostomies might not be valued or prioritized (p = 0.002). Respondents also differed in fear of contracting COVID-19 (69 % PFC vs. 49 % HCP group, p = 0.009); concern for hospitalization (55.5 % PFC vs. 27 % HCP, p < 0.001); access to medical personnel (34 % PFC vs. 14 % HCP, p = 0.005); and concern about canceled appointments (62 % PFC vs. 41 % HCP, p = 0.01). Respondents from both groups reported severe stress and fatigue, sleep deprivation, lack of breaks, and lack of support (70 % PFC vs. 65 % HCP, p = 0.54). Virtual telecare seldom met perceived needs.

CONCLUSION

PFC with a tracheostomy perceived most risks more acutely than HCP in this global sample. Broad stakeholder engagement is necessary to achieve creative, patient-driven solutions to maintain connection, communication, and access for patients with a tracheostomy.

Moving Beyond Detection: Charting a Path to Eliminate Health Care Disparities in Otolaryngology

The coronavirus pandemic has illuminated long-standing inequities in America's health care system and societal structure. While numerous studies have identified health care disparities within our specialty, few have progressed beyond detection. Otolaryngologists have the opportunity and the responsibility to act. Within this article, leaders from otolaryngology share their experience and perspective on health care disparities, including (1) a discussion of disparities in otolaryngology, (2) a summary of health care system design and incentives, (3) an overview of implicit bias, and (4) practical recommendations for providers to advance their awareness of health care disparities and the actions to mitigate them. While the path forward can be daunting, it should not be a deterrent. Throughout the course of this article, numerous resources are provided to support these efforts. To move ahead, our specialty needs to advance our level of understanding and develop, implement, and disseminate successful interventions toward the goal of eliminating health care disparities.

Tackling the Minority Tax: A Roadmap to Redistributing Engagement in Diversity, Equity, and Inclusion Initiatives

Academic medical centers striving to implement diversity, equity, and inclusion (DEI) and antiracism initiatives often ask faculty to volunteer substantial time to committee work, recruitment, mentoring, community, and administrative responsibilities. These requests are not in lieu of current workload and seldom count toward scholarship; the service may go unrecognized, unrewarded, and uncompensated. URiM faculty (underrepresented in medicine) providing such service thus pay a minority tax when precious time is syphoned away from career-advancing activities and personal growth. The resulting strain on available resources has social, psychological, and monetary ramifications that can undermine the long-term objectives of DEI initiatives. We examine the facets of the minority tax, consider the current state of diversity, and present a roadmap to redistribute, reform, and reduce URiM taxation through shared engagement in DEI initiatives. Key interventions include ascribing value to DEI efforts, implementing evidence-based policies to reduce bias, and promoting mentorship, sponsorship, and allyship.

Encountering the social determinants of health on a COVID-19 ICU: Frontline providers' perspectives on inequality in a time of pandemic

Efforts to improve health equity may be advanced by understanding health care providers' perceptions of the causes of health inequalities. Drawing on data from in-depth interviews with nurses and registered respiratory therapists (RRTs) who served on intensive care units (ICUs) during the first surge of the pandemic, this paper examines how frontline providers perceive and attribute the unequal impacts of COVID-19. It shows that nurses and RRTs quickly perceived the pandemic's disproportionate burden on Black and Latinx individuals and families. Providers attribute these inequalities to the social determinants of health, and also raise questions about how barriers to healthcare access may have made some patients more vulnerable to the worst consequences of COVID-19. Providers' perceptions of inequality and its consequences on COVID-19 ICUs were emotionally impactful and distressing, suggesting that this is a critical moment for offering clinicians practical strategies for understanding and addressing the persistent structural inequities that cause racial inequalities in health.

Honesty and Transparency, Indispensable to the Clinical Mission-Part I: How Tiered Professionalism Interventions Support Teamwork and Prevent Adverse Events

At the foundation of clinical medicine is the relationship among patients, families, and health care professionals. Implicit to that social contract, professionals pledge to bring clinical excellence to advance their patients' wellness and healing-and to prevent harm. Patients trust that those privileged to deliver care will do so unwaveringly in service of patients' best interests; however, the incentives and infrastructure surrounding health care delivery can promote or undermine individual performance, teamwork, and patient safety. Modeling professionalism and identifying slips and lapses supports pursuit of high reliability. Part 1, Promoting Professionalism, introduces the first of 3 pillars of advancing the clinical mission.

Benefits of developing graduate medical education programs in community health systems

The creation of new CMS-funded Graduate Medical Education (GME) cap positions by the Consolidated Appropriations Act 2021 offers a unique opportunity for systems in community and rural settings to develop and expand their training programs. This article provides a review of the evidence behind the value proposition for system administrators to foster the growth of GME in community health systems. The infrastructure needed to accredit GME programs may reduce the cost of care for both the patients and the system through improved patient outcomes and facilitation of system efforts to recognize and mitigate social determinants of health. Residents, fellows and medical students expand the capacity of the current healthcare workforce of a system by providing coverage during healthcare emergencies and staffing services in difficult-to-recruit specialties. Those trainees are the nucleus of succession planning for the current medical staff, can facilitate the creation and expansion of service lines, and may elevate the profile of the system through scholarly work and equity and quality improvement activities. While creating GME programs in a community health system may, at first glance, be perceived as cost-prohibitive, there are robust advantages to a system for their creation.