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Sabin J, Nagasawa P, Guenther G, Kett P, Williams-York B, Naidu A, Frogner BK. Implicit and Explicit Race and Weight Biases Among Physician Assistant Preceptors and Trainees. J Physician Assist Educ 2025; 36:167-175. [PMID: 39878705 DOI: 10.1097/jpa.0000000000000657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2025]
Abstract
INTRODUCTION As new equity, diversity, and inclusion programs emerge in physician assistant/associate (PA) education, there is a need to assess baseline levels of implicit and explicit biases among PA preceptors' and trainees. The objectives of this study were (1) to measure implicit and explicit race (Black/White) and weight (fat/thin) biases among PA preceptors and trainees and (2) to identify potential gaps in PA preceptor and trainee education. METHODS This is a cross-sectional study of PA preceptors and trainees from one program operating in several US states; implicit and explicit race and antifat biases and receipt of prior education were measured. RESULTS Preceptor response rate was 6.4% (N = 78) from an eligible population of 1222, and trainee response rate was 25.7% (n = 43) from an eligible population of 167. Sixty-eight preceptor participants (87.2%) and 23 trainees (53.5%) identified as White. Preceptors held strong (Cohen d = 0.81), and trainees held moderate (Cohen d = 0.43) pro-White implicit bias. Overall, preceptors and trainees held little and no explicit race bias (Cohen d = 0.18 and d = 0.0, respectively). Preceptors and trainees held strong implicit antifat bias (Cohen d = 1.24 and Cohen d = 0.76). Preceptors held moderate explicit antifat bias (Cohen d = 0.65); trainees held strong explicit antifat bias (Cohen d = 0.95). Trainees received significantly more education on working with diverse populations compared with preceptors (100% vs. 57.7%, P < 0.001) and working with patients who are overweight (74.4% vs. 41.0%, P < 0.001). DISCUSSION Implicit race and antifat bias exists among our sample of PA preceptors and trainees. A gap in education for preceptors on working with diverse populations and patients who are overweight was identified. Future research should address both.
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Affiliation(s)
- Janice Sabin
- Janice Sabin, PhD, MSW, is a research professor of Department of Biomedical Informatics and Medical Education, School of Medicine at University of Washington, Seattle, Washington
- Pamela Nagasawa, PhD, is an associate professor, with a joint appointment in the Department of Biomedical Informatics and Medical Education, and the Department of Family Medicine, associate program director of Evaluation and Assessment at the MEDEX Physician Assistant Program, University of Washington, School of Medicine, Seattle, Washington
- Grace Guenther, MPA, is a research scientist at Center for Health Workforce Studies, Department of Family Medicine, University of Washington, School of Medicine, Seattle, Washington
- Paula Kett, PhD, MPH, KN, is a research scientist at Center for Health Workforce Studies, University of Washington, School of Medicine, Seattle, Washington
- Bernadette Williams-York, PT, DSc, is an associate professor and director of Division of Physical Therapy, Department of Rehabilitation Medicine at University of Washington, School of Medicine, Seattle, Washington
- Amee Naidu, MMS, PA-CGCS, is an associate program director of Student Affairs, interim associate program director of Academic Affairs, associate teaching professor University of Washington, Department of Family Medicine, MEDEXNW-Physician Assistant Program, Seattle, Washington
- Bianca K. Frogner, PhD, is a professor and director at Center for Health Workforce Studies, Department of Family Medicine, University of Washington, School of Medicine, Seattle, Washington
| | - Pamela Nagasawa
- Janice Sabin, PhD, MSW, is a research professor of Department of Biomedical Informatics and Medical Education, School of Medicine at University of Washington, Seattle, Washington
- Pamela Nagasawa, PhD, is an associate professor, with a joint appointment in the Department of Biomedical Informatics and Medical Education, and the Department of Family Medicine, associate program director of Evaluation and Assessment at the MEDEX Physician Assistant Program, University of Washington, School of Medicine, Seattle, Washington
- Grace Guenther, MPA, is a research scientist at Center for Health Workforce Studies, Department of Family Medicine, University of Washington, School of Medicine, Seattle, Washington
- Paula Kett, PhD, MPH, KN, is a research scientist at Center for Health Workforce Studies, University of Washington, School of Medicine, Seattle, Washington
- Bernadette Williams-York, PT, DSc, is an associate professor and director of Division of Physical Therapy, Department of Rehabilitation Medicine at University of Washington, School of Medicine, Seattle, Washington
- Amee Naidu, MMS, PA-CGCS, is an associate program director of Student Affairs, interim associate program director of Academic Affairs, associate teaching professor University of Washington, Department of Family Medicine, MEDEXNW-Physician Assistant Program, Seattle, Washington
- Bianca K. Frogner, PhD, is a professor and director at Center for Health Workforce Studies, Department of Family Medicine, University of Washington, School of Medicine, Seattle, Washington
| | - Grace Guenther
- Janice Sabin, PhD, MSW, is a research professor of Department of Biomedical Informatics and Medical Education, School of Medicine at University of Washington, Seattle, Washington
- Pamela Nagasawa, PhD, is an associate professor, with a joint appointment in the Department of Biomedical Informatics and Medical Education, and the Department of Family Medicine, associate program director of Evaluation and Assessment at the MEDEX Physician Assistant Program, University of Washington, School of Medicine, Seattle, Washington
- Grace Guenther, MPA, is a research scientist at Center for Health Workforce Studies, Department of Family Medicine, University of Washington, School of Medicine, Seattle, Washington
- Paula Kett, PhD, MPH, KN, is a research scientist at Center for Health Workforce Studies, University of Washington, School of Medicine, Seattle, Washington
- Bernadette Williams-York, PT, DSc, is an associate professor and director of Division of Physical Therapy, Department of Rehabilitation Medicine at University of Washington, School of Medicine, Seattle, Washington
- Amee Naidu, MMS, PA-CGCS, is an associate program director of Student Affairs, interim associate program director of Academic Affairs, associate teaching professor University of Washington, Department of Family Medicine, MEDEXNW-Physician Assistant Program, Seattle, Washington
- Bianca K. Frogner, PhD, is a professor and director at Center for Health Workforce Studies, Department of Family Medicine, University of Washington, School of Medicine, Seattle, Washington
| | - Paula Kett
- Janice Sabin, PhD, MSW, is a research professor of Department of Biomedical Informatics and Medical Education, School of Medicine at University of Washington, Seattle, Washington
- Pamela Nagasawa, PhD, is an associate professor, with a joint appointment in the Department of Biomedical Informatics and Medical Education, and the Department of Family Medicine, associate program director of Evaluation and Assessment at the MEDEX Physician Assistant Program, University of Washington, School of Medicine, Seattle, Washington
- Grace Guenther, MPA, is a research scientist at Center for Health Workforce Studies, Department of Family Medicine, University of Washington, School of Medicine, Seattle, Washington
- Paula Kett, PhD, MPH, KN, is a research scientist at Center for Health Workforce Studies, University of Washington, School of Medicine, Seattle, Washington
- Bernadette Williams-York, PT, DSc, is an associate professor and director of Division of Physical Therapy, Department of Rehabilitation Medicine at University of Washington, School of Medicine, Seattle, Washington
- Amee Naidu, MMS, PA-CGCS, is an associate program director of Student Affairs, interim associate program director of Academic Affairs, associate teaching professor University of Washington, Department of Family Medicine, MEDEXNW-Physician Assistant Program, Seattle, Washington
- Bianca K. Frogner, PhD, is a professor and director at Center for Health Workforce Studies, Department of Family Medicine, University of Washington, School of Medicine, Seattle, Washington
| | - Bernadette Williams-York
- Janice Sabin, PhD, MSW, is a research professor of Department of Biomedical Informatics and Medical Education, School of Medicine at University of Washington, Seattle, Washington
- Pamela Nagasawa, PhD, is an associate professor, with a joint appointment in the Department of Biomedical Informatics and Medical Education, and the Department of Family Medicine, associate program director of Evaluation and Assessment at the MEDEX Physician Assistant Program, University of Washington, School of Medicine, Seattle, Washington
- Grace Guenther, MPA, is a research scientist at Center for Health Workforce Studies, Department of Family Medicine, University of Washington, School of Medicine, Seattle, Washington
- Paula Kett, PhD, MPH, KN, is a research scientist at Center for Health Workforce Studies, University of Washington, School of Medicine, Seattle, Washington
- Bernadette Williams-York, PT, DSc, is an associate professor and director of Division of Physical Therapy, Department of Rehabilitation Medicine at University of Washington, School of Medicine, Seattle, Washington
- Amee Naidu, MMS, PA-CGCS, is an associate program director of Student Affairs, interim associate program director of Academic Affairs, associate teaching professor University of Washington, Department of Family Medicine, MEDEXNW-Physician Assistant Program, Seattle, Washington
- Bianca K. Frogner, PhD, is a professor and director at Center for Health Workforce Studies, Department of Family Medicine, University of Washington, School of Medicine, Seattle, Washington
| | - Amee Naidu
- Janice Sabin, PhD, MSW, is a research professor of Department of Biomedical Informatics and Medical Education, School of Medicine at University of Washington, Seattle, Washington
- Pamela Nagasawa, PhD, is an associate professor, with a joint appointment in the Department of Biomedical Informatics and Medical Education, and the Department of Family Medicine, associate program director of Evaluation and Assessment at the MEDEX Physician Assistant Program, University of Washington, School of Medicine, Seattle, Washington
- Grace Guenther, MPA, is a research scientist at Center for Health Workforce Studies, Department of Family Medicine, University of Washington, School of Medicine, Seattle, Washington
- Paula Kett, PhD, MPH, KN, is a research scientist at Center for Health Workforce Studies, University of Washington, School of Medicine, Seattle, Washington
- Bernadette Williams-York, PT, DSc, is an associate professor and director of Division of Physical Therapy, Department of Rehabilitation Medicine at University of Washington, School of Medicine, Seattle, Washington
- Amee Naidu, MMS, PA-CGCS, is an associate program director of Student Affairs, interim associate program director of Academic Affairs, associate teaching professor University of Washington, Department of Family Medicine, MEDEXNW-Physician Assistant Program, Seattle, Washington
- Bianca K. Frogner, PhD, is a professor and director at Center for Health Workforce Studies, Department of Family Medicine, University of Washington, School of Medicine, Seattle, Washington
| | - Bianca K Frogner
- Janice Sabin, PhD, MSW, is a research professor of Department of Biomedical Informatics and Medical Education, School of Medicine at University of Washington, Seattle, Washington
- Pamela Nagasawa, PhD, is an associate professor, with a joint appointment in the Department of Biomedical Informatics and Medical Education, and the Department of Family Medicine, associate program director of Evaluation and Assessment at the MEDEX Physician Assistant Program, University of Washington, School of Medicine, Seattle, Washington
- Grace Guenther, MPA, is a research scientist at Center for Health Workforce Studies, Department of Family Medicine, University of Washington, School of Medicine, Seattle, Washington
- Paula Kett, PhD, MPH, KN, is a research scientist at Center for Health Workforce Studies, University of Washington, School of Medicine, Seattle, Washington
- Bernadette Williams-York, PT, DSc, is an associate professor and director of Division of Physical Therapy, Department of Rehabilitation Medicine at University of Washington, School of Medicine, Seattle, Washington
- Amee Naidu, MMS, PA-CGCS, is an associate program director of Student Affairs, interim associate program director of Academic Affairs, associate teaching professor University of Washington, Department of Family Medicine, MEDEXNW-Physician Assistant Program, Seattle, Washington
- Bianca K. Frogner, PhD, is a professor and director at Center for Health Workforce Studies, Department of Family Medicine, University of Washington, School of Medicine, Seattle, Washington
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Paganini GA, Weaver AE, Carroll A, Ruben MA, Mathur VA, Paige Lloyd E. Leveraging insights from the psychological science of gender stereotyping to advance scholarship on gender-diverse individuals' pain experiences. THE JOURNAL OF PAIN 2025:105430. [PMID: 40379067 DOI: 10.1016/j.jpain.2025.105430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2024] [Revised: 04/10/2025] [Accepted: 05/02/2025] [Indexed: 05/19/2025]
Abstract
There is evidence of gender disparities in pain experience and pain care as well as the role of stereotypes in perpetuating discriminatory care, however most of this work focuses on comparisons between cisgender men and women; little is known about gender-diverse individuals' pain experiences and outcomes. We consider the value of extending existing cisgender-focused frameworks to understand how the application of gender stereotypes in clinical care contribute to pain care disparities and perpetuate bias, stigma, and discrimination experienced by gender-diverse people. First, we review the literature on stereotype content and stereotype application processes that are theorized to contribute to gender discrimination in pain treatment. We then leverage this extant framework to conduct a novel empirical investigation into the culturally endorsed pain-relevant stereotypes (i.e., trustworthiness, competence, mental illness, and emotional dramatization) of transgender men, transgender women, and nonbinary individuals (as well as cisgender men and cisgender women for replication and comparison purposes). We find that a sample of U.S. adult participants (N = 221) consistently endorsed more negative cultural stereotypes relevant to pain for gender-diverse than cisgender individuals illustrating how stereotype application may undermine high quality and equitable pain treatment of gender-diverse individuals. Based on our findings, we illustrate how this stereotype application may manifest in clinical contexts. Finally, we integrate existing social psychological theorizing to identify opportunities to decrease the impact of stereotypes in the clinical pain encounters. PERSPECTIVE: Gender-diverse individuals experience pain care disparities, which are in part attributable to cultural stereotypes. Building upon stereotyping theory and research from social psychology, we show that pain-relevant negative stereotypes are applied to gender-diverse individuals and highlight opportunities to interrupt stereotype application in clinical interactions to improve health equity.
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Affiliation(s)
| | - Adele E Weaver
- Department of Psychology, University of Rhode Island, USA
| | | | - Mollie A Ruben
- Department of Psychology, University of Rhode Island, USA
| | - Vani A Mathur
- Department of Psychological & Brain Sciences, Texas A&M University, USA
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Rein C. Attachment as a Primary Mechanism in Physician Cognition and Bias During Complex Medical Cases: A Narrative Review. ADVANCES IN MEDICAL EDUCATION AND PRACTICE 2025; 16:713-728. [PMID: 40329988 PMCID: PMC12053435 DOI: 10.2147/amep.s496784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/18/2024] [Accepted: 04/24/2025] [Indexed: 05/08/2025]
Abstract
Introduction In recent decades, improvements in diagnostic accuracy in medical cases have been minimal despite rapid advancements in technology. Moreover, in complex cases, diagnostic accuracy remains a significant challenge, often reflecting practices from the 18th and 19th centuries. This comprehensive narrative review explores how cognitive bias may act as a critical, yet neglected, factor contributing to the persistent diagnostic error rate. Methods A narrative review of the literature was conducted through a search of the George Washington University library databases and Google Scholar to identify studies related to physician cognition, complex medical diagnosis, and cognitive error. Results This review synthesizes existing literature to propose a theoretical framework explaining how cognitive error, clinician cognition, tolerance of uncertainty, and attachment theory interact to influence the formation of cognitive bias at the cost of diagnostic accuracy and efficiency. Discussion It is not only necessary for clinicians to focus on a patient's words, symptoms, or data to improve diagnostic accuracy, but also for clinicians to relate to others' distress through their own attachment styles: technology's critical blind spot. Clinicians with insecure attachment styles may struggle with metacognition, exhibit lower cognitive flexibility, have reduced tolerance for uncertainty, experience lower thresholds for cognitive load, and rely more heavily on heuristics, leading to an increased likelihood of cognitive error during complex medical cases. This theory provides a foundation for further research into how attachment influences clinician decision-making and diagnostic performance while also highlighting how medical education may reinforce these patterns.
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Affiliation(s)
- Carrie Rein
- Department of Clinical Research and Leadership, the George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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Do Bú E, Eggly S, Penner L, Hagiwara N. "The doctor will see you now… but not for long": Linking physicians' racial attitudes and patients' discrimination experiences to racial disparities in the duration of medical consultations. PATIENT EDUCATION AND COUNSELING 2025; 134:108653. [PMID: 39827770 DOI: 10.1016/j.pec.2025.108653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2024] [Accepted: 01/08/2025] [Indexed: 01/22/2025]
Abstract
OBJECTIVE To investigate the relationship between non-Black physicians' racial attitudes, Black patients' discrimination experiences, and consultation duration in diverse clinical settings. METHODS Secondary analyses were conducted on data from three prior studies involving non-Black primary care physicians (Study 1: n = 14, Study 2: n = 5) and their Black patients (Study 1: n = 118, Study 2: n = 31), as well as 15 non-Black oncologists and their 72 Black patients (Study 3). Data included physician and patient surveys, along with video-recorded consultations. RESULTS Study 1 revealed that, relative to other physicians, physicians whose racial attitudes fit an aversive racist profile (i.e., low explicit racial bias, high implicit bias) had longer consultations with Black patients who reported more (vs. fewer) discrimination experiences. Study 2 and 3 found that physicians' implicit racial bias is negatively associated with consultation duration. Finally, a meta-analysis supported the effects of aversive racism and patients' discrimination experiences on consultation duration. DISCUSSION These findings demonstrate how physicians' racial attitudes and patients' discrimination experiences can affect medical consultation duration-an important aspect of patient-provider communication quality. PRACTICAL VALUE These results provide initial evidence for the importance of helping physicians manage the negative consequences of their implicit bias within the current structural constraints of limited medical consultation time and empowering Black patients to advocate for their healthcare needs.
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Affiliation(s)
- Emerson Do Bú
- Institute of Social Sciences, University of Lisbon, Lisbon, Portugal; Department of Psychology, ISCTE - University Institute of Lisbon, Lisbon, Portugal.
| | - Susan Eggly
- Department of Oncology, Wayne State University/Karmanos Cancer Institute, Detroit, MI, USA
| | - Louis Penner
- Department of Oncology, Wayne State University/Karmanos Cancer Institute, Detroit, MI, USA
| | - Nao Hagiwara
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
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Foltz D, Badolato GM, Schultz TR, Patel SJ, Payne AS, Morrison S, Boyle M, Goyal MK. Behavioral Health Flag Use by Race and Ethnicity in a Pediatric Emergency Department. JAMA Netw Open 2025; 8:e259502. [PMID: 40343694 PMCID: PMC12065025 DOI: 10.1001/jamanetworkopen.2025.9502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2024] [Accepted: 03/07/2025] [Indexed: 05/11/2025] Open
Abstract
Importance Behavioral health flags are intended to serve as safety alerts for staff by identifying patients at risk of aggression but may also be prone to racial bias, leading to inequities in care. Objective To investigate racial and ethnic differences in the use of an aggression risk evaluation tool and being labeled as high aggression risk in the electronic health record among youths presenting to a pediatric emergency department. Design, Setting, and Participants This cross-sectional study of electronic health record data was conducted at a single-center pediatric emergency department. Visits from patients aged 21 years or younger presenting with mental health-related concerns between January 2020 and December 2022 were included. Exposure Patient race and ethnicity (Hispanic, non-Hispanic Black [hereafter, Black], non-Hispanic White [hereafter, White], or other, which includes individuals who identify as American Indian or Alaska Native, Asian, multiple races, or any other race). Main Outcomes and Measures The primary outcomes were (1) the use of an aggression risk evaluation tool by a psychiatric social worker, (2) being labeled with a high aggression risk behavioral health flag, or (3) being labeled with a high aggression risk behavioral health flag with a history of violent behavior documented with no other aggression risk behaviors documented. Separate logistic regression models were used to examine association of race and ethnicity with each outcome. Results There were 5121 visits for mental health concerns. The majority of patients were female (3198 patients [62.5%]) and publicly insured (3161 patients [61.8%), with a mean (SD) age of 13.8 (2.7) years. With regard to race and ethnicity, 3061 patients (59.8%) were Black, 893 patients (17.4%) were Hispanic, 778 (15.2%) were White, and 389 (7.6%) belonged to other racial and ethnic groups. Most visits (4119 visits [80.4%]) had an aggression risk evaluation tool completed, and 627 (15.2%) were labeled with a high aggression risk behavioral health flag. There were no racial and ethnic differences in use of the aggression risk evaluation tool. Compared with White youths, Black youths were more likely to be labeled as high aggression risk (60 White youths [9.8%] vs 486 Black youths [19.8%]; adjusted odds ratio, 1.71; 95% CI 1.24-2.35). Among patients who had a history of violent behavior and no other aggression risk behaviors documented on the evaluation tool, Black patients had higher odds of being labeled as high aggression risk compared with White patients (72 Black patients [32.4%] vs 3 White patients [10.7%]; odds ratio, 4.00; 95% CI, 1.16-13.69). Conclusions and Relevance In this cross-sectional study, Black youths were more likely to be labeled with a high aggression risk behavioral health flag despite similar responses to an aggression risk evaluation tool. Processes to ensure equitable care delivery are critically needed.
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Affiliation(s)
- Danielle Foltz
- Center for Translational Research, Children’s National Hospital, Washington, DC
| | - Gia M. Badolato
- Center for Translational Research, Children’s National Hospital, Washington, DC
| | - Theresa Ryan Schultz
- Center for Translational Research, Children’s National Hospital, Washington, DC
- Department of Pediatrics, George Washington University Hospital, Washington, DC
| | - Shilpa J. Patel
- Center for Translational Research, Children’s National Hospital, Washington, DC
- Department of Pediatrics, George Washington University Hospital, Washington, DC
| | - Asha S. Payne
- Center for Translational Research, Children’s National Hospital, Washington, DC
- Department of Pediatrics, George Washington University Hospital, Washington, DC
| | - Sephora Morrison
- Center for Translational Research, Children’s National Hospital, Washington, DC
- Department of Pediatrics, George Washington University Hospital, Washington, DC
| | - Meleah Boyle
- Center for Translational Research, Children’s National Hospital, Washington, DC
- Department of Pediatrics, George Washington University Hospital, Washington, DC
| | - Monika K. Goyal
- Center for Translational Research, Children’s National Hospital, Washington, DC
- Department of Pediatrics, George Washington University Hospital, Washington, DC
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Mason HRC, Webber A, Wyatt TR, Chakraverty D, Russell RG, Havemann C, Boatright D, Farid H, Moss S, Nguyen M. Understanding the Medical Education Experiences of Low-Income Students Through a Maslow's Hierarchy of Needs Lens: An Exploratory Qualitative Study. J Gen Intern Med 2025; 40:1367-1377. [PMID: 39789274 PMCID: PMC12045838 DOI: 10.1007/s11606-024-09161-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Accepted: 10/17/2024] [Indexed: 01/12/2025]
Abstract
BACKGROUND Diversity in the physician workforce is critical for quality patient care. Students from low-income backgrounds represent an increasing proportion of medical school matriculants, yet little research has addressed their medical school experiences. OBJECTIVE To explore the medical school experiences of students from low-income backgrounds using a modified version of Maslow's Hierarchy of Needs (physiologic, safety, love/belonging, esteem, and self-actualization) as a theoretical framework. DESIGN We conducted an exploratory qualitative study through in-depth, semi-structured interviews. PARTICIPANTS Forty-two low-income medical students attending US-based MD or DO degree-granting institutions. APPROACH We conducted a content analysis of interview transcripts using deductive and inductive coding. We discussed our independent analyses to reach consensus and shared findings with a subgroup of participants for member checking. RESULTS Participants described substantial challenges in meeting their basic needs. Unmet physiologic needs included food insecurity, lack of adequate sleep/rest, and poor mental health. Unmet safety needs included lack of reliable transportation and safe housing; threats to financial safety included debt and an inability to cover both medical education-related and non-medical education-related expenses. Unmet belonging needs included difficulty connecting with peers or participating in financially inaccessible social activities. Unmet respect/esteem needs stemmed from bias from peers, teachers, and institutions. Unmet self-actualization needs were uncommon. Participants felt pride in their medical journey; however, some perceived that their financial struggles hindered them from realizing their full potential. CONCLUSIONS Previously reported attrition and adverse academic outcomes among low-income students may be linked to challenges they experience trying to more fully meet important human needs. This finding underscores the need to approach wellness holistically and ensure students do not exist in a prolonged state of unmet needs. Recommendations that accreditation bodies and medical schools could implement to promote tailored support for low-income and other marginalized learners are provided.
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Affiliation(s)
- Hyacinth R C Mason
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA.
| | - Alexis Webber
- Department of General Surgery, Albany Medical Center, Albany, NY, USA
| | - Tasha R Wyatt
- Center for Health Professions Education, Uniformed Services University, Bethesda, MD, USA
| | - Devasmita Chakraverty
- Ravi J. Matthai Centre for Educational Innovation, Indian Institute of Management Ahmedabad, Ahmedabad, GJ, India
| | - Regina G Russell
- Program Evaluation and Institutional Effectiveness, Vanderbilt University School of Nursing, Nashville, TN, USA
| | | | - Dowin Boatright
- Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
- Emergency Medicine and Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Huma Farid
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Mytien Nguyen
- MD/PhD Program, Yale School of Medicine, New Haven, CT, USA
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Lawendy B, Bhatti T, Adekunle AD, Rubens M, Babajide O, Sedarous M, Tariq T, Okafor PN. Higher Inpatient Racial and Ethnic Diversity Is Associated with Better Outcomes in Hispanic and Native American Patients for Gastrointestinal Diseases. Dig Dis Sci 2025:10.1007/s10620-025-09004-z. [PMID: 40198527 DOI: 10.1007/s10620-025-09004-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2024] [Accepted: 03/17/2025] [Indexed: 04/10/2025]
Abstract
BACKGROUND Evidence suggests that outcomes are poorer among patients from historically marginalized racial and ethnic backgrounds. The impact of patient racial and ethnic diversity on gastrointestinal outcomes is understudied. AIMS To investigate the impact of patient racial/ethnic diversity on gastrointestinal disease (GI) outcomes. METHODS Using the 2019 National Inpatient Sample (NIS), hospital inpatient racial/ethnic diversity was defined as the percentage of Hispanic or Native American discharges. We included gastrointestinal bleeding, inflammatory bowel diseases, gastrointestinal obstruction, cirrhosis, and alcohol-associated hepatitis. Logistic regression was used to predict outcomes [major complications (MCC), long length of stay, high total charges], controlling for age, gender, location, income quartile, hospital size, and region. RESULTS Our cohort included 537,830 hospitalizations. In the unadjusted analyses, MCC rates were higher among Hispanic (24.8%) and Native American patients (30.4%), compared to Whites (18.3%). In adjusted analyses, compared to Whites, Hispanic [adjusted odds ratio (OR) 1.21, 95% Confidence Interval (CI) 1.15-1.28] and Native American patients [OR 1.25, (95% CI) 1.09-1.43] had higher MCC rates. As hospital Hispanic diversity increased, MCC for Hispanics improved [OR 0.93, (95% CI) 0.87-1.14] and were even better among Native American patients as their diversity increased [OR 0.83, (95% CI) 0.73-0.94] (Table 1). A similar trend was observed in the 2018 validation cohort. CONCLUSION Increasing hospital inpatient Hispanic and Native American diversity is associated with better outcomes for these groups. Further research is needed on the impact cultural competence and linguistic concordance on gastrointestinal outcomes.
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Affiliation(s)
| | | | | | - Muni Rubens
- Office of Clinical Research, Miami Cancer Institute, Miami, FL, USA
| | - Oyedotun Babajide
- Department of Gastroenterology, New York Medical College, New York City, NY, USA
| | - Mary Sedarous
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Tahniyat Tariq
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA, USA
| | - Philip N Okafor
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA.
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Hagiwara N, Rivet E, Eiler BA, Edwards C, Harika N, Jones SCT, Grover AC, Mende-Siedlecki P. Study protocol for investigating racial disparities in pain care: a comprehensive integration of patient-level and provider-level mechanisms with dyadic communication processes using a mixed-methods research design. BMJ Open 2025; 15:e090365. [PMID: 40147996 PMCID: PMC11956359 DOI: 10.1136/bmjopen-2024-090365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Accepted: 03/12/2025] [Indexed: 03/29/2025] Open
Abstract
INTRODUCTION Although many efforts have been made to reduce racial pain disparities over decades, the pain of black patients is still undertreated. Previous work has identified a host of patient and provider factors that contribute to racial disparities in healthcare in general, and consequently, may contribute to disparities in pain care in particular. That said, there has been limited clinically meaningful progress in eliminating these disparities. This lack of progress is likely because prior research has investigated the influence of patient and provider factors in isolation, rather than examining their interaction. Successful pain care requires constructive patient-provider communication, and constructive communication is both dyadic and dynamic. One well-accepted operationalisation of such dyadic processes is behavioural coordination. We hypothesise that the pain of black patients continues to be undertreated because black patients are more likely than white patients to participate in racially discordant medical interactions (ie, seeing other-race providers) and experience disruptions in behavioural coordination. We further hypothesise that disruptions in behavioural coordination will reflect patient and provider factors identified in prior research. We propose to test these hypotheses in the planned surgical context. METHODS AND ANALYSIS Using a convergent mixed methods research design, we will collect data from at least 15 surgeons and their 150 patients (approximately equal number of black and white patients per surgeon). The data sources will include one surgeon survey, four patient surveys, video- and/or audio-recordings of preoperative consultations and medical chart reviews. The recorded preoperative consultations will be analysed both qualitatively and quantitatively to assess the magnitude and pattern of behavioural coordination between patients and surgeons. Those data will be linked to survey data and data from medical chart reviews to test our hypotheses. ETHICS AND DISSEMINATION Ethical approval has been obtained from the Virginia Commonwealth University Institutional Review Board (HM20023574). Findings will be disseminated through presentations at scientific conferences, publications in peer-reviewed journals and speaking engagements with clinician stakeholders. We will also share the main findings from this project with patients via a newsletter on completion of the entire project.
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Affiliation(s)
- Nao Hagiwara
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA
| | - Emily Rivet
- Department of Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Brian A Eiler
- Department of Psychology, Davidson College, Davidson, North Carolina, USA
| | | | - Nadia Harika
- Department of Pediatrics, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Shawn C T Jones
- Department of Psychology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Amelia C Grover
- Department of Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
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9
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Sabin J, Mick E, Eisdorfer E, Yazdani M, Garcia MM, Hale JF, Terrien J, Puerto G, Duodu V, Zolezzi-Wyndham V, Rumbut J, Calista J, Valdman O, Potts S, Allison J, Pugnaire M, Tjia J. Defensive Responses to Implicit Association Tests and Bias Awareness in an Implicit Bias Mitigation Training. ADVANCES IN MEDICAL EDUCATION AND PRACTICE 2025; 16:419-430. [PMID: 40124633 PMCID: PMC11930236 DOI: 10.2147/amep.s492884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2024] [Accepted: 02/25/2025] [Indexed: 03/25/2025]
Abstract
Background Implicit bias education that utilizes the Implicit Association Test (IAT) to raise self-awareness of bias can induce defensiveness. Objective To describe clinical learners' bias awareness, self-perceptions of bias relative to colleagues (better-than-average), implicit and explicit biases and defensive response to the IATs. Design Cross-sectional study. Participants Internal medicine and family medicine residents, and Doctor of Nursing Practice students at a public medical and nursing school affiliated with a disproportionate share hospital and who completed an implicit bias recognition and mitigation educational program (including didactics, IATs, and communication skills training and practice with standardized patients) in 2018-2019. Main Measures We measured implicit and explicit attitudes and stereotypes, reactions to IAT results (defensive or not defensive), better-than-average perceptions, bias awareness and participants' characteristics. We examined associations between defensive responses to the IAT and participant characteristics, self-reported explicit biases, bias awareness within self, society, and healthcare, and IAT scores. Key Results Of N=61 respondents, 57% were female and 59% White. We found moderate implicit bias favoring White people versus Black people, weak bias favoring White people versus Hispanic/Latinx people and moderate bias favoring White people on both race and ethnicity medical compliance stereotype IATs. Participants demonstrated awareness of bias in society and healthcare, but not within self. Eighteen percent were defensive regarding their IAT results. Perceptions of own bias (self) were always of their having less bias than their colleagues, and they were better-than-average. There were no statistically significant associations between IAT scores and participant demographics and no interaction effect between implicit bias, defensiveness and better-than-average scores. Conclusion Clinical learners hold moderate implicit biases, believe they have less bias than others, and almost 1-in-5 have a defensive response to IAT feedback. It is important to design implicit bias educational interventions to include reflection on personal bias and provide a safe environment to minimize defensiveness.
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Affiliation(s)
- Janice Sabin
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, USA
| | - Eric Mick
- Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, MA, USA
| | - Ethan Eisdorfer
- Department of Family Medicine, UMass Chan Medical School, Worcester, MA, USA
| | - Majid Yazdani
- Department of Medicine, UMass Chan Medical School, Worcester, MA, USA
| | - Maria M Garcia
- Department of Medicine, UMass Chan Medical School, Worcester, MA, USA
| | - Janet Fraser Hale
- Tan Chingfen Graduate School of Nursing, UMass Chan Medical School, Worcester, MA, USA
| | - Jill Terrien
- Tan Chingfen Graduate School of Nursing, UMass Chan Medical School, Worcester, MA, USA
| | - Geraldine Puerto
- Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, MA, USA
| | - Vennesa Duodu
- Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, MA, USA
| | | | - Joshua Rumbut
- Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, MA, USA
| | | | - Olga Valdman
- Department of Family Medicine, UMass Chan Medical School, Worcester, MA, USA
| | - Stacy Potts
- Department of Family Medicine, UMass Chan Medical School, Worcester, MA, USA
| | - Jeroan Allison
- Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, MA, USA
| | - Michele Pugnaire
- Department of Family Medicine, UMass Chan Medical School, Worcester, MA, USA
| | - Jennifer Tjia
- Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, MA, USA
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10
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Elizabeth Baetzel A, Holman A, Dobija N, Reynolds PI, Nafiu O. Racial Disparities in Pediatric Anesthesia: An Updated Review. Anesthesiol Clin 2025; 43:67-81. [PMID: 39890323 DOI: 10.1016/j.anclin.2024.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2025]
Abstract
Health care disparities affect care across all medical fields, including pediatric anesthesia. Recent studies have revealed differences in pediatric perioperative care especially in anesthetic and analgesic choices. Additionally, Black children face higher 30 day postoperative mortality and more serious adverse events compared to White children. While strategies to address these disparities have been proposed, significant work is still needed.
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Affiliation(s)
- Anne Elizabeth Baetzel
- Section of Pediatric Anesthesiology, University of Michigan, 1540 East Medical Center Drive, 4-911 C. S. Mott Children's Hospital, Ann Arbor, MI 48109, USA.
| | - Ashlee Holman
- Section of Pediatric Anesthesiology, University of Michigan, 1540 East Medical Center Drive, 4-911 C. S. Mott Children's Hospital, Ann Arbor, MI 48109, USA
| | - Nicole Dobija
- Section of Pediatric Anesthesiology, University of Michigan, 1540 East Medical Center Drive, 4-911 C. S. Mott Children's Hospital, Ann Arbor, MI 48109, USA
| | - Paul Irvin Reynolds
- Section of Pediatric Anesthesiology, University of Michigan, 1540 East Medical Center Drive, 4-911 C. S. Mott Children's Hospital, Ann Arbor, MI 48109, USA
| | - Olubukola Nafiu
- Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 42305, USA
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11
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Crump A, Al-Jorani MS, Ahmed S, Abrol E, Jain S. Implicit bias assessment by career stage in medical education training: a narrative review. BMC MEDICAL EDUCATION 2025; 25:137. [PMID: 39875909 PMCID: PMC11776257 DOI: 10.1186/s12909-024-06319-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2024] [Accepted: 11/06/2024] [Indexed: 01/30/2025]
Abstract
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.
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Affiliation(s)
- Alisha Crump
- School of Pharmacy, University of Maryland, Postdoctoral Fellow, Baltimore, MD, US.
| | - May Saad Al-Jorani
- College of Medicine, Medical Student, Mustansiriyah University, Baghdad, Iraq
| | - Sunya Ahmed
- St. George's University, School of Medicine West Indies, Medical Student, West Indies, Grenada
| | - Ekas Abrol
- The University of Illinois Cancer Center, Research Specialist, Chicago, IL, US
| | - Shikha Jain
- University of Illinois Chicago, College of Medicine, Associate Professor of Medicine, Chicago, IL, US
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12
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Ragland DA, Cecora AJ, Ben-Ari E, Solis J, Montgomery SR, Papalia AG, Virk MS. Racial and ethnic disparity in shoulder surgery: a systematic review. J Shoulder Elbow Surg 2025; 34:203-211. [PMID: 39103086 DOI: 10.1016/j.jse.2024.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 06/10/2024] [Accepted: 06/17/2024] [Indexed: 08/07/2024]
Abstract
BACKGROUND Health care disparity exists in utilization and delivery of musculoskeletal care and continues to be an obstacle for orthopedic health care providers to mitigate. Racial and ethnic disparities exist within various surgical fields including orthopedic surgery and are expected to continue to rise in upcoming years. The aim of this systematic review is to analyze the racial and ethnic disparities on utilization and outcomes after common shoulder surgical procedures. METHODS A primary literature search was performed using PubMed, Embase, Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov databases using comprehensive Medical Subject Headings and subject-heading search terms. Studies were included if they reported utilization and or outcomes across 2 or more racial/ethnic groups in patients (age >16) who underwent total shoulder arthroplasty (TSA), rotator cuff repair (RCR), arthroscopic Bankart repair, Latarjet procedure, and open reduction internal fixation of proximal humerus fracture (PHF). Baseline demographics, data on procedure utilization, perioperative measures including mortality, operative time, length of stay, readmission, and complications were extracted from included studies, and descriptive statistical analysis performed. RESULTS Eighteen studies were identified for full text review of which 13 found race and ethnicity as factors affecting utilization and outcomes in TSA, RCR, arthroscopic Bankart repair, Latarjet procedure, and open reduction internal fixation of PHF. Compared to White patients, Black patients were found to have decreased utilization, longer length of stay, and greater operative time and mortality after TSA; Black patients also had longer operative times and time to discharge, and lower levels of reported satisfaction after RCR. Hispanic/Latino ethnicity was reported as an independent risk factor for postoperative falls following TSA. Hispanic/Latino and Black patients have a higher risk of delayed surgery and greater risk of readmission after surgical treatment of PHF compared to patients of White race. CONCLUSION This systematic review highlights the limited literature reporting the existence of racial and ethnic disparities in utilization and outcomes after common shoulder surgical procedures. Additionally, there is a paucity of studies exploring the underlying etiology of racial and ethnic disparity in outcomes after shoulder surgery. More research is necessary to pave the way for evidence-based action plans to mitigate health care disparities after shoulder surgeries, but this review serves as a baseline for where efforts in direct improvement can begin.
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Affiliation(s)
- DaShaun A Ragland
- Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Andrew J Cecora
- Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Erel Ben-Ari
- Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Javier Solis
- Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Samuel R Montgomery
- Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Aidan G Papalia
- Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Mandeep S Virk
- Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA.
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13
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Duffy CMC, Bú ED, Pereira CR, Madeira F, Hagiwara N. Healthcare providers' psychological investment in clinical recommendations: Investigating the role of implicit racial attitudes. Soc Sci Med 2024; 362:117435. [PMID: 39447379 PMCID: PMC11615868 DOI: 10.1016/j.socscimed.2024.117435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 09/20/2024] [Accepted: 10/18/2024] [Indexed: 10/26/2024]
Abstract
Racial disparities in clinical recommendations can result in racial disparities in health. While healthcare providers' implicit racial attitudes (affective component of bias) are theorized to be one major factor contributing to racial disparities in clinical recommendations, empirical evidence to support the link is lacking. This study aimed to bridge this gap by moving beyond the standard approach of operationalizing the quality of clinical recommendations as a guideline-consistent vs. -inconsistent dichotomy. The present secondary study examined the role of provider implicit racial attitudes in the quality of clinical recommendations, operationalized as behaviors reflecting providers' psychological investment in patient care (i.e., number of words used to describe clinical recommendations, and number of treatment options recommended). Two-hundred-and-ten White medical trainees reviewed a clinical vignette of either a White or Black male patient and provided clinical recommendations. Their implicit racial attitudes were evaluated using the Implicit Association Test. Participants with more biased implicit racial attitudes (i.e., stronger implicit preference for White vs. Black individuals) used fewer words to describe their clinical recommendations and provided fewer clinical recommendations for the Black (vs. White) patient, while there were no significant differences between Black and White patients among participants with less biased implicit racial attitudes. These results illustrate the insidious impact of implicit racial attitudes in healthcare provision and underscore the need for researchers to consider the complex, nuanced ways in which provider implicit racial attitudes might manifest in clinical decision-making.
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Affiliation(s)
- Conor M C Duffy
- Department of Psychology, Virginia Commonwealth University, USA.
| | - Emerson Do Bú
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA; Institute of Social Sciences, University of Lisbon, Portugal.
| | - Cícero Roberto Pereira
- Institute of Social Sciences, University of Lisbon, Portugal; Department of Psychology, Federal University of Paraíba, Brazil
| | - Filipa Madeira
- Institute of Social Sciences, University of Lisbon, Portugal
| | - Nao Hagiwara
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
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14
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Turner L, Taylor S, Ward A, Thistlethwaite F, Yorke J. The Barriers and Enablers to Participation in Oncology Clinical Trials for Ethnically Diverse Communities: A Qualitative Systematic Review Using Metaethnography. Cancer Nurs 2024:00002820-990000000-00307. [PMID: 40106657 DOI: 10.1097/ncc.0000000000001399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2025]
Abstract
BACKGROUND Racial and ethnic inequities exist in cancer clinical trial participation. Low recruitment across ethnically diverse communities contributes to health inequalities further disproportionately affecting these groups. Understanding barriers and enablers to clinical trial participation for ethnic minorities is key to developing strategies to address this problem. OBJECTIVE To explore, evaluate, and synthesize qualitative research surrounding patients' lived experiences and perceptions of participating in cancer clinical trials from ethnically diverse groups. METHODS Noblit and Hare's 7-stage metaethnography was used. Seven databases were searched. Inclusion criteria were as follows: qualitative studies published in English from January 1, 2012, to January 31, 2022; patients from any ethnic minority 18 years and older with a cancer diagnosis; and cancer patients' carers and healthcare professionals (HCPs)/healthcare leaders involved in the delivery of cancer clinical trials. RESULTS The majority of included articles were conducted in the United States. Interpretive qualitative synthesis resulted in 7 categories including patient perceptions and beliefs and HCP perception of trial burden and social determinants of health. Four lines of argument were established. CONCLUSIONS The findings capture the experience and perceptions of ethnic minority patients, their carers, HCPs, and healthcare leaders in this area of research. Incongruities exist between patient-reported barriers and those perceived by HCPs. Published empirical research outside the United States is limited. IMPLICATIONS FOR PRACTICE When developing strategies to increase clinical trial participation, research literacy, cultural safety, and unconscious biases within healthcare need to be addressed. Further research to examine intersectionality and the role of faith in decision-making among ethnic groups is warranted.
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Affiliation(s)
- Lorraine Turner
- Author Affiliations: Department of Research & Innovation (Ms Turner) and Christie Patient Centred Research (Dr Taylor, Ms Ward and Professor Yorke), The Christie NHS Foundation Trust; School of Nursing, Midwifery and Social Work, The University of Manchester (Ms Turner and Professor Yorke); Department of Medical Oncology, The Christie NHS Foundation Trust (Professor Thistlethwaite); and Division of Cancer Sciences, School of Medical Sciences, The University of Manchester (Professor Thistlethwaite), Manchester, United Kingdom
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15
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Ramtin S, Rajagopalan D, Ring D, Crijns T, Jayakumar P. Musculoskeletal surgeons have implicit bias towards the biomedical paradigm of human illness. PLoS One 2024; 19:e0310119. [PMID: 39446829 PMCID: PMC11500957 DOI: 10.1371/journal.pone.0310119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 08/23/2024] [Indexed: 10/26/2024] Open
Abstract
BACKGROUND Evidence is mounting that the biopsychosocial paradigm is more accurate and useful than the biomedical paradigm of care. Habits of thought can hinder the implementation of this knowledge into daily care strategies. To understand and lessen these potential barriers, we asked: 1) What is the relative implicit and explicit attitudes of musculoskeletal surgeons towards the biomedical or biopsychosocial paradigms of medicine? 2) What surgeon factors are associated with these attitudes? METHODS An online survey-based experiment was distributed to members of the Science of Variation Group (SOVG) with a total of 163 respondents. Implicit bias towards the biomedical or biopsychosocial paradigms was measured using an Implicit Association Test (IAT) designed by our team using open-source software; explicit preferences were measured using ordinal scales. RESULTS On average, surgeons demonstrated a moderate implicit bias towards the biomedical paradigm (d-score: -0.21; Interquartile range [IQR]: -0.56 to 0.19) and a moderate explicit preference towards the biopsychosocial paradigm (mean: 14; standard deviation: 14). A greater implicit bias towards the biomedical paradigm was associated with male surgeons (d-score: -0.30; IQR: -0.57 to 0.14; P = 0.005). A greater explicit preference towards the biomedical paradigm was independently associated with a European practice location (Regression coefficient: -9.1; 95% CI: -14 to -4.4; P <0.001) and trauma subspecialty (RC: -6.2; 95% CI: -11 to -1.0; P <0.001). CONCLUSIONS The observation that surgeons have an implicit bias favoring the biomedical paradigm might inform strategies for implementation of care strategies based on evidence favoring the biopsychosocial paradigm.
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Affiliation(s)
- Sina Ramtin
- The University of Texas Dell Medical School, Austin, Texas, United States of America
| | - Dayal Rajagopalan
- The University of Texas Dell Medical School, Austin, Texas, United States of America
| | - David Ring
- The University of Texas Dell Medical School, Austin, Texas, United States of America
| | - Tom Crijns
- The University of Texas Dell Medical School, Austin, Texas, United States of America
| | - Prakash Jayakumar
- The University of Texas Dell Medical School, Austin, Texas, United States of America
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16
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Peled Y, Ducharme A, Kittleson M, Bansal N, Stehlik J, Amdani S, Saeed D, Cheng R, Clarke B, Dobbels F, Farr M, Lindenfeld J, Nikolaidis L, Patel J, Acharya D, Albert D, Aslam S, Bertolotti A, Chan M, Chih S, Colvin M, Crespo-Leiro M, D'Alessandro D, Daly K, Diez-Lopez C, Dipchand A, Ensminger S, Everitt M, Fardman A, Farrero M, Feldman D, Gjelaj C, Goodwin M, Harrison K, Hsich E, Joyce E, Kato T, Kim D, Luong ML, Lyster H, Masetti M, Matos LN, Nilsson J, Noly PE, Rao V, Rolid K, Schlendorf K, Schweiger M, Spinner J, Townsend M, Tremblay-Gravel M, Urschel S, Vachiery JL, Velleca A, Waldman G, Walsh J. International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024. J Heart Lung Transplant 2024; 43:1529-1628.e54. [PMID: 39115488 DOI: 10.1016/j.healun.2024.05.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 05/14/2024] [Indexed: 08/18/2024] Open
Abstract
The "International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024" updates and replaces the "Listing Criteria for Heart Transplantation: International Society for Heart and Lung Transplantation Guidelines for the Care of Cardiac Transplant Candidates-2006" and the "2016 International Society for Heart Lung Transplantation Listing Criteria for Heart Transplantation: A 10-year Update." The document aims to provide tools to help integrate the numerous variables involved in evaluating patients for transplantation, emphasizing updating the collaborative treatment while waiting for a transplant. There have been significant practice-changing developments in the care of heart transplant recipients since the publication of the International Society for Heart and Lung Transplantation (ISHLT) guidelines in 2006 and the 10-year update in 2016. The changes pertain to 3 aspects of heart transplantation: (1) patient selection criteria, (2) care of selected patient populations, and (3) durable mechanical support. To address these issues, 3 task forces were assembled. Each task force was cochaired by a pediatric heart transplant physician with the specific mandate to highlight issues unique to the pediatric heart transplant population and ensure their adequate representation. This guideline was harmonized with other ISHLT guidelines published through November 2023. The 2024 ISHLT guidelines for the evaluation and care of cardiac transplant candidates provide recommendations based on contemporary scientific evidence and patient management flow diagrams. The American College of Cardiology and American Heart Association modular knowledge chunk format has been implemented, allowing guideline information to be grouped into discrete packages (or modules) of information on a disease-specific topic or management issue. Aiming to improve the quality of care for heart transplant candidates, the recommendations present an evidence-based approach.
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Affiliation(s)
- Yael Peled
- Leviev Heart & Vascular Center, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel; Faculty of Medical & Health Sciences, Tel Aviv University, Tel Aviv, Israel.
| | - Anique Ducharme
- Deparment of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
| | - Michelle Kittleson
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Neha Bansal
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Josef Stehlik
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Shahnawaz Amdani
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, Ohio, USA
| | - Diyar Saeed
- Heart Center Niederrhein, Helios Hospital Krefeld, Krefeld, Germany
| | - Richard Cheng
- Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Brian Clarke
- Division of Cardiology, University of British Columbia, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Fabienne Dobbels
- Academic Centre for Nursing and Midwifery, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Maryjane Farr
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX; Parkland Health System, Dallas, TX, USA
| | - JoAnn Lindenfeld
- Division of Cardiovascular Medicine, Vanderbilt University, Nashville, TN, USA
| | | | - Jignesh Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Deepak Acharya
- Division of Cardiovascular Diseases, University of Arizona Sarver Heart Center, Tucson, Arizona, USA
| | - Dimpna Albert
- Department of Paediatric Cardiology, Paediatric Heart Failure and Cardiac Transplant, Heart Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Saima Aslam
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Alejandro Bertolotti
- Heart and Lung Transplant Service, Favaloro Foundation University Hospital, Buenos Aires, Argentina
| | - Michael Chan
- University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Sharon Chih
- Heart Failure and Transplantation, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Monica Colvin
- Department of Cardiology, University of Michigan, Ann Arbor, MI; Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Maria Crespo-Leiro
- Cardiology Department Complexo Hospitalario Universitario A Coruna (CHUAC), CIBERCV, INIBIC, UDC, La Coruna, Spain
| | - David D'Alessandro
- Massachusetts General Hospital, Boston; Harvard School of Medicine, Boston, MA, USA
| | - Kevin Daly
- Boston Children's Hospital & Harvard Medical School, Boston, MA, USA
| | - Carles Diez-Lopez
- Advanced Heart Failure and Heart Transplant Unit, Department of Cardiology, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Anne Dipchand
- Division of Cardiology, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Melanie Everitt
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Alexander Fardman
- Leviev Heart & Vascular Center, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel; Faculty of Medical & Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Marta Farrero
- Department of Cardiology, Hospital Clínic, Barcelona, Spain
| | - David Feldman
- Newark Beth Israel Hospital & Rutgers University, Newark, NJ, USA
| | - Christiana Gjelaj
- Department of Cardiovascular and Thoracic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Matthew Goodwin
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Kimberly Harrison
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eileen Hsich
- Cleveland Clinic Foundation, Division of Cardiovascular Medicine, Cleveland, OH, USA
| | - Emer Joyce
- Department of Cardiology, Mater University Hospital, Dublin, Ireland; School of Medicine, University College Dublin, Dublin, Ireland
| | - Tomoko Kato
- Department of Cardiology, International University of Health and Welfare School of Medicine, Narita, Chiba, Japan
| | - Daniel Kim
- University of Alberta & Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Me-Linh Luong
- Division of Infectious Disease, Department of Medicine, University of Montreal Hospital Center, Montreal, Quebec, Canada
| | - Haifa Lyster
- Department of Heart and Lung Transplantation, The Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Harefield, Middlesex, UK
| | - Marco Masetti
- Heart Failure and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Johan Nilsson
- Department of Cardiothoracic and Vascular Surgery, Skane University Hospital, Lund, Sweden
| | | | - Vivek Rao
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Katrine Rolid
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Kelly Schlendorf
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Joseph Spinner
- Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Madeleine Townsend
- Division of Pediatric Cardiology, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Maxime Tremblay-Gravel
- Deparment of Medicine, Montreal Heart Institute, Université?de Montréal, Montreal, Quebec, Canada
| | - Simon Urschel
- Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Jean-Luc Vachiery
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Angela Velleca
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Georgina Waldman
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - James Walsh
- Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane; Heart Lung Institute, The Prince Charles Hospital, Brisbane, Australia
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17
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Vorawandthanachai T, Lambert C, Tavella N, Gonzalez CM, Hughes F. The Effect of Implicit Bias on the OB/GYN Residency Application Process. J Grad Med Educ 2024; 16:557-563. [PMID: 39416413 PMCID: PMC11475431 DOI: 10.4300/jgme-d-23-00601.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 02/23/2024] [Accepted: 07/23/2024] [Indexed: 10/19/2024] Open
Abstract
Background Medical students from racially minoritized backgrounds receive negative evaluations more frequently, possibly from implicit bias. Objective To determine if a preference for White applicants over Asian and Black applicants exists among resident and attending reviewers of obstetrics and gynecology (OB/GYN) residency applications. Methods In 2021, we sampled academic OB/GYN physicians from 6 academic institutions to randomly receive questionnaire form A or B, each containing 4 contrived Electronic Residency Application Service profiles stratified by United States Medical Licensing Examination scores; institutions attended; and strength of recommendation letters into top-, mid-, and low-tiers. Form A applicants were White top-tier, White mid-tier without resilience, Asian mid-tier with resilience, and White low-tier. Form B applicants were Black top-tier, Asian mid-tier without resilience, White mid-tier with resilience, and White low-tier applicants. Both questionnaires' profiles were identical except for applicants' names and races. The primary outcome was participants' rankings of applicants from most to least desirable. Baseline characteristics of participants were compared with chi-square tests. Rankings were compared using generalized estimating equations to calculate the odds ratio (significance P<.05). Results One hundred and ninety-one were invited to participate; 109 participants started the questionnaire, and 103 ranked applicants (response rate 54%). Fifty-three participants completed form A, and 56 completed form B. No significant differences were found in participants' demographics. Participants frequently ranked White applicants significantly more highly than Black applicants (-3.3, 95% CI -3.5, -3.1) and Asian applicants (-3.3, 95% CI -3.5, -3.1). Conclusions Despite identical qualifications, a stronger preference for White applicants over Black or Asian applicants was found.
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Affiliation(s)
- Thammatat Vorawandthanachai
- Thammatat Vorawandthanachai, MD, is a PGY-2 Resident, Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, New York, USA
| | - Calvin Lambert
- Calvin Lambert, MD, is Assistant Professor, Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nicola Tavella
- Nicola Tavella, MPH, is Clinical Research Program Director, Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Cristina M. Gonzalez
- Cristina M. Gonzalez, MD, MEd, is Associate Director, Institute for Excellence in Health Equity and Professor of Medicine and Population Health, New York University Grossman School of Medicine, New York, New York, USA; and
| | - Francine Hughes
- Francine Hughes, MD, is Professor, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology and Women’s Health, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA
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18
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Gonzalez CM, Greene RE, Cooper LA, Lypson ML. Recommendations for Faculty Development in Addressing Implicit Bias in Clinical Encounters and Clinical Learning Environments. J Gen Intern Med 2024; 39:2326-2332. [PMID: 38831249 PMCID: PMC11347534 DOI: 10.1007/s11606-024-08832-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 05/20/2024] [Indexed: 06/05/2024]
Affiliation(s)
- Cristina M Gonzalez
- Institute for Excellence in Health Equity, New York University Grossman School of Medicine, New York, NY, USA.
- Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA.
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA.
| | - Richard E Greene
- Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
- Office of Diversity Affairs, NYU Grossman School of Medicine, New York, NY, USA
| | - Lisa A Cooper
- Department of Medicine, Johns Hopkins University School of Medicine and Johns Hopkins Center for Health Equity, Baltimore, MD, USA
| | - Monica L Lypson
- Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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Imms K, Anika M, Al-Shaikhli SA, Ali M, Montesino B, Khan S, Akhouri S, Toonkel RL. Examining the Role of Gender and Ethnic Concordance in Medical Student Specialty Selection. MEDICAL SCIENCE EDUCATOR 2024; 34:847-855. [PMID: 39099862 PMCID: PMC11296992 DOI: 10.1007/s40670-024-02044-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/09/2024] [Indexed: 08/06/2024]
Abstract
Introduction Representation of female and minority physicians varies across specialties and may influence career selection by medical students. To investigate the effect of demographic concordance between medical students and clinical role models on specialty selection, we conducted a survey of graduating medical students to assess the perceived importance and influence of third-year clerkship experiences with demographically concordant preceptors on their choice of specialty for post-graduate training. Methods An 11-question survey was shared nationally through AAMC Organizational Student Representatives to medical students in the Class of 2023. Information gathered included demographics; specialty of choice; extent of exposure to preceptors of the same gender, race, or ethnicity during clinical clerkships; and perceived importance and influence of those interactions (Likert 1-5, Low-High) on specialty selection. Results A total of 84 students responded. Female students ascribed more importance to gender concordance with preceptors on the third-year clerkship most associated with their specialty of choice than males [3.4 (SD 1.2) vs. 1.3 (SD 0.8) respectively, p < 0.0001] and greater influence to gender concordance on final specialty selection [2.37 (SD 1.1) vs. 1.31 (SD 0.8) respectively, p < 0.0001]. Non-Caucasians ascribed more importance to race/ethnicity concordance than Caucasians [2.8 (SD 1.4) vs. 1.2 (SD 0.5) respectively, p < 0.0001] and greater influence to race/ethnicity concordance on final specialty selection [2.0 (SD 1.3) vs. 1.1 (SD 0.4) respectively, p < 0.0001]. Caucasian females ascribed the greatest importance to gender concordance (p < 0.001), non-Caucasian females ascribed the greatest influence of gender concordance (p < 0.001), and non-Caucasian females ascribed both the greatest importance (p < 0.001) and influence (p < 0.001) to race/ethnicity concordance. Conclusions We found that gender and race/ethnicity concordance between students and clinical preceptors during third year clerkships is perceived as especially important and influential in specialty selection by minority and female medical students. These findings highlight the importance of diversity in gender and race/ethnicity representation by preceptors on clinical clerkships. Supplementary Information The online version contains supplementary material available at 10.1007/s40670-024-02044-6.
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Affiliation(s)
- Kayla Imms
- Florida International University, Herbert Wertheim College of Medicine, 11200 SW 8th St AHC2, Miami, FL 33199 USA
| | - Maisha Anika
- Florida International University, Herbert Wertheim College of Medicine, 11200 SW 8th St AHC2, Miami, FL 33199 USA
| | - Seema Azim Al-Shaikhli
- Florida International University, Herbert Wertheim College of Medicine, 11200 SW 8th St AHC2, Miami, FL 33199 USA
| | - Maryam Ali
- Florida International University, Herbert Wertheim College of Medicine, 11200 SW 8th St AHC2, Miami, FL 33199 USA
| | - Brittany Montesino
- Florida International University, Herbert Wertheim College of Medicine, 11200 SW 8th St AHC2, Miami, FL 33199 USA
| | - Samara Khan
- Florida International University, Herbert Wertheim College of Medicine, 11200 SW 8th St AHC2, Miami, FL 33199 USA
| | - Shweta Akhouri
- Florida International University, Herbert Wertheim College of Medicine, 11200 SW 8th St AHC2, Miami, FL 33199 USA
| | - Rebecca L. Toonkel
- Florida International University, Herbert Wertheim College of Medicine, 11200 SW 8th St AHC2, Miami, FL 33199 USA
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Howard KA, Witrick B, Clark A, Morse A, Atkinson K, Kapoor P, McGinigle KL, Minc S, Alabi O, Hicks CW, Gonzalez A, Cené CW, Cykert S, Kalbaugh CA. Investigating Unconscious Race Bias and Bias Awareness Among Vascular Surgeons. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.06.04.24308457. [PMID: 38883745 PMCID: PMC11177910 DOI: 10.1101/2024.06.04.24308457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
Background Implicit bias can influence behavior and decision-making. In clinical settings, implicit bias may influence treatment decisions and contribute to health disparities. Given documented Black-White disparities in vascular care, the purpose of this study was to examine the prevalence and degree of unconscious bias and awareness of bias among vascular surgeons treating peripheral artery disease (PAD). Methods The sampling frame included all vascular surgeons who participate in the Vascular Quality Initiative (VQI). Participants completed a survey which included demographic questions, the race implicit association test (IAT) to measure magnitude of unconscious bias, and six bias awareness questions to measure conscious bias. The magnitude of unconscious bias was no preference; or slight, moderate, or strong in the direction of pro-White or pro-Black. Data from participants were weighted to account for nonresponse bias and known differences in the characteristics of surgeons who chose to participate compared to the full registry. We stratified unconscious and conscious findings by physician race/ethnicity, physician sex, and years of experience. Finally, we examined the relationship between unconscious and conscious bias. Results There were 2,512 surgeons in the VQI registry, 304 of whom completed the survey, including getting IAT results. Most participants (71.6%) showed a pro-White bias with 73.0% of this group in the moderate and strong categories. While 77.5% of respondents showed conscious awareness of bias, of those whose conscious results showed lack of awareness, 67.8% had moderate or strong bias, compared to 55.7% for those with awareness. Bias magnitude varied based on physician race/ethnicity and years of experience. Women were more likely than men to report awareness of biases and potential impact of bias on decision-making. Conclusions Most people have some level of unconscious bias, developed from early life reinforcements, social stereotypes, and learned experiences. Regarding health disparities, however, these are important findings in a profession that takes care of patients with PAD due to heavy burden of comorbid conditions and high proportion of individuals from structurally vulnerable groups. Given the lack of association between unconscious and conscious awareness of biases, awareness may be an important first step in mitigation to minimize racial disparities in healthcare.
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Affiliation(s)
- Kerry A Howard
- Department of Public Health Sciences, Clemson University, Clemson, SC
- Center for Public Health Modeling and Response, Clemson University, Clemson, SC
| | - Brian Witrick
- Department of Public Health Sciences, Clemson University, Clemson, SC
| | - Ashley Clark
- Center for Survey Research and O’Neill School of Public and Environmental Affairs, Indiana University-Bloomington, Bloomington, IN
| | - Avery Morse
- Department of Public Health Sciences, Clemson University, Clemson, SC
| | - Karen Atkinson
- Department of Public Health Sciences, Clemson University, Clemson, SC
| | - Pranav Kapoor
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health-Bloomington, Bloomington, IN
| | - Katharine L. McGinigle
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill NC
| | - Samantha Minc
- Department of Cardiovascular and Thoracic Surgery, West Virginia School of Medicine, Morgantown, WV
| | - Olamide Alabi
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Caitlin W Hicks
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrew Gonzalez
- Department of Surgery, School of Medicine, Indiana University School of Medicine; Indianapolis, IN
- Center for Health Services Research, Regenstrief Institute
| | - Crystal W. Cené
- Department of Medicine, University of California at San Diego Health, La Jolla, CA
| | - Samuel Cykert
- Division of General Medicine and Clinical Epidemiology, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill NC
| | - Corey A. Kalbaugh
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health-Bloomington, Bloomington, IN
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21
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van Bruggen S, Bennett RJ, Manchaiah V, Jager LBD, Swanepoel DW. Perceptions of Hearing Health Care: A Qualitative Analysis of Satisfied and Dissatisfied Online Reviews. Am J Audiol 2024; 33:386-410. [PMID: 38483218 DOI: 10.1044/2024_aja-23-00180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024] Open
Abstract
PURPOSE The aim of this study was to examine the hearing health care experience of satisfied and dissatisfied consumers as reported on Google reviews. METHOD Using qualitative thematic analysis, open-text responses from Google regarding hearing health care clinics across 40 U.S. cities were examined. During the original search, 13,168 reviews were identified. Purposive sampling led to a total of 8,420 five-star reviews and 321 one-star reviews. The sample consisted of 500 five-star (satisfied) and 234 one-star (dissatisfied) reviews, describing experiences with audiology clinics, excluding reviews related to ear, nose, and throat services; other medical specialties; and those not relevant to hearing health care. RESULTS Satisfied and dissatisfied consumer reviews yielded nuanced dimensions of the hearing health care consumer experience, which were grouped into distinct domains, themes, and subthemes. Six and seven domains were identified from the satisfied and dissatisfied reviews, encompassing 23 and 26 themes, respectively. The overall experience domain revealed emotions ranging from contentment and gratitude to dissatisfaction and waning loyalty. The clinical outcomes domain highlights the pivotal contribution of well-being and hearing outcomes to the consumer experience, while the standard of care domain underscores shared expectations for punctuality, person-centered care, and efficient communication. Facility quality, professional competence, and inclusive care were also highlighted across positive and negative reviews. CONCLUSIONS Findings indicate dimensions of satisfied and dissatisfied hearing health care consumer experiences, identifying areas for potential service refinement. These consumer experiences inform person-centric service delivery in hearing health care.
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Affiliation(s)
- Sanchia van Bruggen
- Department of Speech-Language Pathology and Audiology, University of Pretoria, South Africa
| | - Rebecca Jane Bennett
- National Acoustic Laboratories, Macquarie University, Sydney, New South Wales, Australia
- enAble Institute, Curtin University, Perth, Western Australia, Australia
- Ear Science Institute Australia, Subiaco, Western Australia, Australia
| | - Vinaya Manchaiah
- Department of Speech-Language Pathology and Audiology, University of Pretoria, South Africa
- Virtual Hearing Lab (a collaborative initiative between the University of Colorado and the University of Pretoria), Aurora, CO
- Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine, Aurora
- UCHealth Hearing and Balance, University of Colorado Hospital, Aurora
- Department of Speech and Hearing, School of Allied Health Sciences, Manipal University, India
| | - Leigh Biagio-de Jager
- Department of Speech-Language Pathology and Audiology, University of Pretoria, South Africa
| | - De Wet Swanepoel
- Department of Speech-Language Pathology and Audiology, University of Pretoria, South Africa
- Virtual Hearing Lab (a collaborative initiative between the University of Colorado and the University of Pretoria), Aurora, CO
- Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine, Aurora
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22
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Cheng SM, McKinney CC, Hurtado-de-Mendoza A, Chan S, Graves KD. Confidence, Connection & Collaboration: Creating a Scalable Bias Reduction Improvement Coaching Train-the-Trainer Program to Mitigate Implicit Bias across a Medical Center. TEACHING AND LEARNING IN MEDICINE 2024; 36:381-398. [PMID: 37074228 DOI: 10.1080/10401334.2023.2201289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 03/08/2023] [Indexed: 05/03/2023]
Abstract
Problem: Academic medical centers need to mitigate the negative effects of implicit bias with approaches that are empirically-based, scalable, sustainable, and specific to departmental needs. Guided by Kotter's Model of Change to create and sustain cultural change, we developed the Bias Reduction Improvement Coaching Program (BRIC), a two-year, train-the-trainer implicit bias coaching program designed to meet the increasing demand for bias training across a university medical center. Intervention: BRIC trained a cohort of faculty and staff as coaches during four quarterly training sessions in Year 1 that covered 1) the science of bias, 2) bias in selection and hiring, 3) bias in mentoring, and 4) bias in promotion, retention, and workplace culture. In Year 2, coaches attended two booster sessions and delivered at least two presentations. BRIC raises awareness of bias mitigation strategies in a scalable way by uniquely building capacity through department-level champions, providing programming that addresses the 'local context,' and setting a foundation for sustained institutional change. Context: In a U.S. academic medical center, 27 faculty and staff from 24 departments were trained as inaugural BRIC coaches. We assessed outcomes at multiple levels: BRIC coach outcomes (feedback on the training sessions; coach knowledge, attitudes, and skills), departmental-level outcomes (program attendee feedback, knowledge, and intentions) and institutional outcomes (activities to sustain change). Impact: After Year 1, coaches reported high satisfaction with BRIC and a statistically significant increase in self-efficacy in their abilities to recognize, mitigate, and teach about implicit bias. In Year 2, attendees at BRIC coach presentations reported an increase in bias mitigation knowledge, and the majority committed to taking follow-up action (e.g., taking an Implicit Association Test). Coaches also launched activities for sustaining change at the broader university and beyond. Lessons Learned: The BRIC Program indicates a high level of interest in receiving bias mitigation training, both among individuals who applied to be BRIC coaches and among presentation attendees. BRIC's initial success supports future expansion. The model appears scalable and sustainable; future efforts will formalize the emerging community of practice around bias mitigation and measure elements of on-going institutional culture change.
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Affiliation(s)
- Susan M Cheng
- Department of Family Medicine, Senior Associate Dean for Diversity, Equity, and Inclusion, Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Caleb C McKinney
- Department of Rehabilitation Medicine, Graduate and Postdoctoral Training & Development, Biomedical Graduate Education, Georgetown University Medical Center, Washington, District of Columbia
| | | | - Samuel Chan
- Office of Diversity, Equity & Inclusion, Georgetown School of Medicine, Washington, District of Columbia, USA
| | - Kristi D Graves
- Department of Oncology and Associate Dean for Faculty Development, Georgetown University Medical Center, Washington, District of Columbia, USA
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23
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Malison KA, Avila-Quintero VJ, Al-Mateen CS, Flores J, Landeros-Weisenberger A, Njoroge WFM, Novins DK, Robles-Ramamurthy B, Taylor JH, Bloch MH, Tobón AL. Racial Implicit Associations in Child Psychiatry. J Am Acad Child Adolesc Psychiatry 2024:S0890-8567(24)00305-8. [PMID: 38823476 DOI: 10.1016/j.jaac.2024.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 03/28/2024] [Accepted: 05/23/2024] [Indexed: 06/03/2024]
Abstract
OBJECTIVE Racial disparities in diagnosis and treatment are prevalent in child psychiatry, including disparate diagnosis rates of internalizing and externalizing disorders in Black and White children. However, limited research has investigated mechanisms that contribute to these disparities. This study examined child racial implicit associations in psychiatric clinicians and medical students to address this gap. METHOD Psychiatrists and trainees completed an online survey including 2 race Implicit Association Tests (IATs) pairing child faces to words with either positive or negative valence, and words related to internalizing or externalizing behavioral problems. Psychiatrists and trainees' demographic predictors of implicit associations were also investigated. RESULTS Data were analyzed from 235 psychiatrists and trainees (112 child and adolescent psychiatrists and fellows) who met inclusion criteria. Psychiatrists and trainees demonstrated greater moderate-to-strong association between Black child faces and "bad" (ie, negatively valenced) words (44.3%) vs "good" (ie, positively valenced) words (6.4%), and between externalizing words (41.7%) vs internalizing words (7.2%). Psychiatrists and trainees' demographic characteristics including being female (β = -0.12; 95% CI = -0.23 to -0.01; p < .05), Black (β = -0.36; 95% CI = -0.54 to -0.18; p < .001), or an attending physician (β = -0.26; 95% CI = -0.45 to -0.06; p = .01) were significant predictors of decreased association between Black child faces and negative valence words. Being female was a significant predictor of decreased association between Black child faces and externalizing words (β = -0.26; 95% CI = -0.45 to -0.06; p = .01). CONCLUSION Participating psychiatrists and trainees demonstrated bias toward associating Black rather than White child faces with negative words and externalizing behavioral problems. Future research should examine the following: racial implicit associations in a more generalizable sample; the relationship between race IATs and provider behavior; and interventions to reduce racial inequities in psychiatry, including individual and systemic solutions. DIVERSITY & INCLUSION STATEMENT We worked to ensure sex and gender balance in the recruitment of human participants. We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants. We worked to ensure that the study questionnaires were prepared in an inclusive way. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented sexual and/or gender groups in science. We actively worked to promote sex and gender balance in our author group. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. One or more of the authors of this paper received support from a program designed to increase minority representation in science.
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Affiliation(s)
| | | | | | - José Flores
- Yale University School of Medicine, New Haven, Connecticut; University of California, Los Angeles, Los Angeles, California
| | | | - Wanjikũ F M Njoroge
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Penn Medicine City, Philadelphia, Pennsylvania
| | - Douglas K Novins
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | - Jerome H Taylor
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Penn Medicine City, Philadelphia, Pennsylvania
| | | | - Amalia Londoño Tobón
- Yale University School of Medicine, New Haven, Connecticut; MedStar Georgetown University Hospital, Washington, District of Columbia.
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24
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Ndjaboue R, Beaudoin C, Comeau S, Dagnault A, Dogba MJ, Numainville S, Racine C, Straus S, Tremblay MC, Witteman HO. Patients as teachers: a within-subjects randomized pilot experiment of patient-led online learning modules for health professionals. BMC MEDICAL EDUCATION 2024; 24:525. [PMID: 38730313 PMCID: PMC11087246 DOI: 10.1186/s12909-024-05473-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 04/25/2024] [Indexed: 05/12/2024]
Abstract
PURPOSE Many health professions education programs involve people with lived experience as expert speakers. Such presentations may help learners better understand the realities of living with chronic illness or experiencing an acute health problem. However, lectures from only one or a small number of people may not adequately illustrate the perspectives and experiences of a diverse patient cohort. Additionally, logistical constraints such as public health restrictions or travel barriers may impede in-person presentations, particularly among people who have more restrictions on their time. Health professions education programs may benefit from understanding the potential effects of online patient-led presentations with a diverse set of speakers. We aimed to explore whether patient-led online learning modules about diabetes care would influence learners' responses to clinical scenarios and to collect learners' feedback about the modules. METHOD This within-subjects randomized experiment involved 26 third-year medical students at Université Laval in Quebec, Canada. Participation in the experiment was an optional component within a required course. Prior to the intervention, participating learners responded to three clinical scenarios randomly selected from a set of six such scenarios. Each participant responded to the other three scenarios after the intervention. The intervention consisted of patient-led online learning modules incorporating segments of narratives from 21 patient partners (11 racialized or Indigenous) describing why and how clinicians could provide patient-centered care. Working with clinical teachers and psychometric experts, we developed a scoring grid based on the biopsychosocial model and set 0.6 as a passing score. Independent evaluators, blinded to whether each response was collected before or after the intervention, then scored learners' responses to scenarios using the grid. We used Fisher's Exact test to compare proportions of passing scores before and after the intervention. RESULTS Learners' overall percentage of passing scores prior to the intervention was 66%. Following the intervention, the percentage of passing scores was 76% (p = 0.002). Overall, learners expressed appreciation and other positive feedback regarding the patient-led online learning modules. DISCUSSION Findings from this experiment suggest that learners can learn to provide better patient-centered care by watching patient-led online learning modules created in collaboration with a diversity of patient partners.
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25
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Gavin JR, Rodbard HW, Battelino T, Brosius F, Ceriello A, Cosentino F, Giorgino F, Green J, Ji L, Kellerer M, Koob S, Kosiborod M, Lalic N, Marx N, Prashant Nedungadi T, Parkin CG, Topsever P, Rydén L, Huey-Herng Sheu W, Standl E, Olav Vandvik P, Schnell O. Disparities in prevalence and treatment of diabetes, cardiovascular and chronic kidney diseases - Recommendations from the taskforce of the guideline workshop. Diabetes Res Clin Pract 2024; 211:111666. [PMID: 38616041 DOI: 10.1016/j.diabres.2024.111666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 03/29/2024] [Accepted: 04/08/2024] [Indexed: 04/16/2024]
Abstract
There is a mounting clinical, psychosocial, and socioeconomic burden worldwide as the prevalence of diabetes, cardiovascular disease (CVD), and chronic kidney disease (CKD) continues to rise. Despite the introduction of therapeutic interventions with demonstrated efficacy to prevent the development or progression of these common chronic diseases, many individuals have limited access to these innovations due to their race/ethnicity, and/or socioeconomic status (SES). However, practical guidance to providers and healthcare systems for addressing these disparities is often lacking. In this article, we review the prevalence and impact of healthcare disparities derived from the above-mentioned chronic conditions and present broad-based recommendations for improving access to quality care and health outcomes within the most vulnerable populations.
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Affiliation(s)
- James R Gavin
- Emory University School of Medicine, Atlanta, GA, USA
| | - Helena W Rodbard
- Endocrine and Metabolic Consultants, 3200 Tower Oaks Blvd., Suite 250, Rockville, MD 20852, USA.
| | - Tadej Battelino
- University Medical Center Ljubljana, and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
| | - Frank Brosius
- University of Arizona College of Medicine, 1501 N. Campbell Ave, Tucson, AZ 85724-5022, USA.
| | - Antonio Ceriello
- IRCCS MultiMedica, Via Milanese 300, Sesto San Giovanni MI 20099, Italy.
| | - Francesco Cosentino
- Cardiology Unit, Department of Medicine, Karolinska Institute and Karolinska University Hospital, Solna, Stockholm, Sweden.
| | - Francesco Giorgino
- Department of Precision and Regenerative Medicine and Ionian Area, Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, University of Bari Aldo Moro, Bari, Italy
| | - Jennifer Green
- Duke University Medical Center, Duke Clinical Research Institute, 641 Durham Centre, Box 17969, Durham, NC 27715, USA.
| | - Linong Ji
- Peking University People's Hospital, 11 Xizhimen S St, Xicheng District, Beijing, China.
| | - Monika Kellerer
- Marienhospital Stuttgart, Böheimstraße 37, Stuttgart 70199, Germany.
| | - Susan Koob
- PCNA National Office, 613 Williamson Street, Suite 200, Madison, WI 53703, USA.
| | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, 4401 Wornall Rd, Kansas City, MO 64111, USA; The George Institute for Global Health and University of New South Wales, Sydney, Australia.
| | - Nebojsa Lalic
- University Clinical Center of Serbia, University of Belgrade, Pasterova 2, Beograd 11000, Serbia
| | - Nikolaus Marx
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University Pauwelsstraße 30, 52074 Aachen, Germany.
| | | | - Christopher G Parkin
- CGParkin Communications, Inc., 2675 Windmill Pkwy, Suite 2721, Henderson, NV 89074, USA
| | - Pinar Topsever
- Department of Family Medicine, Acıbadem Mehmet Ali Aydınlar University School of Medicine, İçerenköy, Kayışdağı Cd. No: 32, Ataşehir/İstanbul 34752, Türkiye.
| | - Lars Rydén
- Department of Medicine K2, Karolinska Institute, Stockholm, Sweden.
| | - Wayne Huey-Herng Sheu
- Institute of Molecular and Genomic Medicine, National Research Health Institutes, Zhunan, Miaoli 350, Taiwan.
| | - Eberhard Standl
- Forschergruppe Diabetes e. V., Ingolstaedter Landstraße 1, Neuherberg, Munich, Germany.
| | - Per Olav Vandvik
- Department of Medicine, Lovisenberg Diaconal Hospital, Institute of Health and Society, University of Oslo, Lovisenberggata 17, Oslo 0456, Norway
| | - Oliver Schnell
- Forschergruppe Diabetes e. V., Ingolstaedter Landstraße 1, Neuherberg, Munich, Germany.
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Bascom E, Casanova-Perez R, Tobar K, Bedmutha MS, Ramaswamy H, Pratt W, Sabin J, Wood B, Weibel N, Hartzler A. Designing Communication Feedback Systems To Reduce Healthcare Providers' Implicit Biases In Patient Encounters. PROCEEDINGS OF THE SIGCHI CONFERENCE ON HUMAN FACTORS IN COMPUTING SYSTEMS. CHI CONFERENCE 2024; 2024:452. [PMID: 38933286 PMCID: PMC11204363 DOI: 10.1145/3613904.3642756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Abstract
Healthcare providers' implicit bias, based on patients' physical characteristics and perceived identities, negatively impacts healthcare access, care quality, and outcomes. Feedback tools are needed to help providers identify and learn from their biases. To incorporate providers' perspectives on the most effective ways to present such feedback, we conducted semi-structured design critique sessions with 24 primary care providers. We found that providers seek feedback designed with transparent metrics indicating the quality of their communication with a patient and trends in communication patterns across visits. Based on these metrics and trends, providers want this feedback presented in a dashboard paired with actionable, personalized tips about how to improve their communication behaviors. Our study provides new insights for interactive systems to help mitigate the impact of implicit biases in patient-provider communication. New systems that build upon these insights could support providers in making healthcare more equitable, particularly for patients from marginalized communities.
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Affiliation(s)
- Emily Bascom
- Information School, University of Washington, Seattle, Washington, USA
| | - Reggie Casanova-Perez
- Biomedical Informatics and Medical Education, University of Washington, Seattle, Washington, USA
| | - Kelly Tobar
- University of California, San Diego, San Diego, California, USA
| | | | | | - Wanda Pratt
- Information School, University of Washington, Seattle, Washington, USA
| | - Janice Sabin
- Biomedical Informatics and Medical Education, University of Washington, Seattle, Washington, USA
| | - Brian Wood
- University of Washington, Seattle, Washington, USA
| | - Nadir Weibel
- Computer Science and Engineering & Design Lab, University of California, San Diego, San Diego, California, USA
| | - Andrea Hartzler
- Biomedical Informatics and Medical Education, University of Washington, Seattle, Washington, USA
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Ganguly AP, Oren H, Jack HE, Abe R. Equity M&M - Adaptation of the Morbidity and Mortality Conference to Analyze and Confront Structural Inequity in Internal Medicine. J Gen Intern Med 2024; 39:867-872. [PMID: 37904072 PMCID: PMC11043282 DOI: 10.1007/s11606-023-08487-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 10/13/2023] [Indexed: 11/01/2023]
Abstract
BACKGROUND At morbidity and mortality (M&M) conferences, medical teams review cases for medical education and system improvement. Adverse outcomes are often driven by social inequity, but processes to analyze such outcomes are lacking. AIM Adapt quality improvement and patient safety (QIPS) tools in the M&M format to systematically analyze adverse patient outcomes rooted in social and structural determinants of health (SSDH). SETTING One-hour conferences conducted in health systems in Seattle, WA, and Dallas, TX. PARTICIPANTS Equity M&M conferences were held 11 times, each with approximately 45 participants comprised of internal medicine trainees, faculty, and non-medical staff. PROGRAM DESCRIPTION Conferences included a case narrative and counternarrative highlighting SSDH, an equity-framed root cause analysis, and potential interventions. PROGRAM EVALUATION Conferences were received well across both institutions. Following conferences, most respondents reported increased identification of opportunities for action towards equity (88.5%) and confidence in discussing equity issues with colleagues (92.3%). DISCUSSION Equity M&M conferences are a structured tool for deconstructing and confronting structural inequity that leads to adverse patient outcomes. Evaluations demonstrate educational impact on participants. Anecdotal examples suggest institutional impact. Other health systems could adopt this model for similar advocacy and system improvement.
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Affiliation(s)
- Anisha P Ganguly
- Center of Innovation and Value at Parkland, Parkland Health, Dallas, TX, USA.
- Division of General Internal Medicine, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Hannah Oren
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Helen E Jack
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Ryan Abe
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
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Zelin NS, Scott C, Avila-Quintero VJ, Curlin K, Flores JM, Bloch MH. Sexual Orientation and Racial Bias in Relation to Medical Specialty. JOURNAL OF HOMOSEXUALITY 2024; 71:574-599. [PMID: 36269161 DOI: 10.1080/00918369.2022.2132441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
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.
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Affiliation(s)
| | - Carter Scott
- Washington University School of Medicine, St. Louis, Missouri, USA
| | | | - Kaveri Curlin
- Irvine School of Medicine, University of California, Irvine, California, USA
| | - Jose M Flores
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michael H Bloch
- Child Study Center, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
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Boolchandani H, Chen L, Elder RW, Osborn R, Phatak UP, Puthenpura V, Sheares BJ, Tiyyagura G, Amster L, Lee S, Langhan ML. Identifying Gender and Racial Bias in Pediatric Fellowship Letters of Recommendation: Do Word Choices Influence Interview Decisions? J Pediatr 2024; 265:113843. [PMID: 37995931 DOI: 10.1016/j.jpeds.2023.113843] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/09/2023] [Accepted: 11/15/2023] [Indexed: 11/25/2023]
Abstract
OBJECTIVES To describe linguistic differences in letters of recommendation (LORs) for pediatric fellowship candidates based on applicant and letter writer demographics and to examine if these differences influenced the decision to interview a candidate for a fellowship position. STUDY DESIGN LORs for applicants to 8 pediatric subspecialty fellowships at a single academic center from the 2020 Match were analyzed in this cross-sectional study. Frequency of validated agentic and communal terms in each letter were determined by a language processing web application. Bias was determined as having a >5% surplus of agentic or communal terms. RESULTS We analyzed 1521 LORs from 409 applicants: 69% were women, 28% were under-represented minorities in medicine (URM), and 50% were invited to interview. Overall, 66% of LORs were agentic biased, 16% communal biased, and 19% neutral. There was no difference in bias in LORs by an applicant's gender (woman 67% agentic vs man 62% agentic; P = .058), race, or ethnicity (non-URM 65% agentic vs URM 67% agentic; P = .660). Despite a lower frequency of agentic terms in LORs for applicants invited for interviews, when accounting for other components of an application and applicant demographics, no significant association was made between language bias in LORs and fellowship interview status. CONCLUSIONS The frequency of agentic and communal terms in LORs for pediatric subspecialty fellowship candidates were not found to influence the decision to invite a candidate to interview. However, raising awareness of potential areas of bias within the pediatric fellowship selection process might lead to a more equitable and holistic approach to application review.
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Affiliation(s)
- Henna Boolchandani
- Department of Pediatrics at Yale University School of Medicine, New Haven, CT
| | - Laura Chen
- Section of Pediatric Pulmonology, Allergy, Immunology, and Sleep Medicine, Department of Pediatrics at Yale University School of Medicine, New Haven, CT
| | - Robert W Elder
- Section of Pediatric Cardiology, Department of Pediatrics at Yale University School of Medicine, New Haven, CT
| | - Rachel Osborn
- Section of Pediatric Hospital Medicine, Department of Pediatrics at Yale University School of Medicine, New Haven, CT
| | - Uma P Phatak
- Section of Pediatric Gastroenterology and Hepatology, Department of Pediatrics at Yale University School of Medicine, New Haven, CT
| | - Vidya Puthenpura
- Section of Pediatric Hematology and Oncology, Department of Pediatrics at Yale University School of Medicine, New Haven, CT
| | - Beverley J Sheares
- Section of Pediatric Pulmonology, Allergy, Immunology, and Sleep Medicine, Department of Pediatrics at Yale University School of Medicine, New Haven, CT
| | - Gunjan Tiyyagura
- Section of Pediatric Emergency Medicine, Department of Pediatrics at Yale University School of Medicine, New Haven, CT
| | | | - Seohyuk Lee
- Yale University School of Medicine, New Haven, CT
| | - Melissa L Langhan
- Section of Pediatric Emergency Medicine, Department of Pediatrics at Yale University School of Medicine, New Haven, CT.
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Barootes HC, Huynh ACA, Maracle M, Istl AC, Wang P, Kirpalani A. "Reduced to My Race Once Again": Perceptions about Underrepresented Minority Medical School Applicants in Canada and the United States. TEACHING AND LEARNING IN MEDICINE 2024; 36:1-12. [PMID: 36351290 DOI: 10.1080/10401334.2022.2141247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 10/13/2022] [Indexed: 06/16/2023]
Abstract
Phenomenon: To increase racial diversity in medical school classes, many institutions have created underrepresented minority (URM) application streams. However, many URM students experience overt and passive marginalization throughout their training and this may be related to how matriculants from URM streams are perceived by their peers. Approach: We conducted a discourse analysis of online discussion forums to explore how URM streams across Canada and the United States are perceived. We analyzed 850 posts from 13 discussion threads published between 2015 and 2020. We used inductive content analysis to develop a data-driven coding scheme from which we identified common themes. Findings: Despite an overall appreciation of the benefits of a diverse workforce, participants engaged in prominent discussions surrounding the merits of URM streams. We identified perceptions that students admitted from URM streams are less academically and clinically competent, with URM applicants reporting feeling unworthy for admission in the eyes of non-URM applicants. Users felt that the influence of socioeconomic status was under-appreciated, and that admissions officers inadequately addressed this barrier. There were some applicants who perceived the admissions process as "broken" with non-URMs displaying a fear of social change, and URMs fearing that the system defines them by their racialized status. Insights: Online discussion forums provide unique insight into perceptions surrounding URM streams. We identified potentially harmful misconceptions about URM students applying to these streams and highlight that actionable measures to reduce marginalization against URM matriculants must begin before medical school.
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Affiliation(s)
- Hailey C Barootes
- Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Children's Hospital, London Health Sciences Centre, London, Ontario, Canada
| | - Albert Cong-Anh Huynh
- Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Marcy Maracle
- Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Alexandra C Istl
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Peter Wang
- Children's Hospital, London Health Sciences Centre, London, Ontario, Canada
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Amrit Kirpalani
- Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Children's Hospital, London Health Sciences Centre, London, Ontario, Canada
- Lawson Health Research Institute, London, Ontario, Canada
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Capers Q, Thomas L. Enhancing the Pipeline for a Diverse Workforce. Child Adolesc Psychiatr Clin N Am 2024; 33:71-76. [PMID: 37981338 DOI: 10.1016/j.chc.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
The lack of diversity in the physician workforce is a multifactorial problem. From elementary school through college, students from minority or socioeconomically disadvantaged backgrounds achieve despite attending underresourced schools, facing low expectations from peers and teachers, and overcoming unconscious biases among decision makers. These and other obstacles lead to significant attrition of talent by the time cohorts prepare to apply to medical school. Pipeline initiatives that inspire and prepare applicants from groups underrepresented in medicine are needed to swell the ranks of diverse individuals entering our profession.
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Affiliation(s)
- Quinn Capers
- Department of Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA.
| | - Lia Thomas
- Department of Psychiatry, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA. https://twitter.com/DrLiaT1
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Medeiros S, Coelho R, Millett C, Saraceni V, Coeli CM, Trajman A, Rasella D, Durovni B, Hone T. Racial inequalities in mental healthcare use and mortality: a cross-sectional analysis of 1.2 million low-income individuals in Rio de Janeiro, Brazil 2010-2016. BMJ Glob Health 2023; 8:e013327. [PMID: 38050408 PMCID: PMC10693873 DOI: 10.1136/bmjgh-2023-013327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 10/15/2023] [Indexed: 12/06/2023] Open
Abstract
INTRODUCTION Mental health inequalities across racial and ethnic groups are large and unjust in many countries, yet these inequalities remain under-researched, particularly in low-income and middle-income countries such as Brazil. This study investigates racial and socioeconomic inequalities in primary healthcare usage, hospitalisation and mortality for mental health disorders in Rio de Janeiro, Brazil. METHODS A cohort of 1.2 million low-income adults from Rio de Janeiro, Brazil with linked socioeconomic, demographic, healthcare use and mortality records was cross-sectionally analysed. Poisson regression models were used to investigate associations between self-defined race/colour and primary healthcare (PHC) usage, hospitalisation and mortality due to mental disorders, adjusting for socioeconomic factors. Interactions between race/colour and socioeconomic characteristics (sex, education level, income) explored if black and pardo (mixed race) individuals faced compounded risk of adverse mental health outcomes. RESULTS There were 272 532 PHC consultations, 10 970 hospitalisations and 259 deaths due to mental disorders between 2010 and 2016. After adjusting for a wide range of socioeconomic factors, the lowest PHC usage rates were observed in black (adjusted rate ratio (ARR): 0.64; 95% CI 0.60 to 0.68; compared with white) and pardo individuals (ARR: 0.87; 95% CI 0.83 to 0.92). Black individuals were more likely to die from mental disorders (ARR: 1.68; 95% CI 1.19 to 2.37; compared with white), as were those with lower educational attainment and household income. In interaction models, being black or pardo conferred additional disadvantage across mental health outcomes. The highest educated black (ARR: 0.56; 95% CI 0.47 to 0.66) and pardo (ARR: 0.75; 95% CI 0.66 to 0.87) individuals had lower rates of PHC usage for mental disorders compared with the least educated white individuals. Black individuals were 3.7 times (ARR: 3.67; 95% CI 1.29 to 10.42) more likely to die from mental disorders compared with white individuals with the same education level. CONCLUSION In low-income individuals in Rio de Janeiro, racial/colour inequalities in mental health outcomes were large and not fully explainable by socioeconomic status. Black and pardo Brazilians were consistently negatively affected, with lower PHC usage and worse mental health outcomes.
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Affiliation(s)
- Sophia Medeiros
- Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, London, UK
| | - Rony Coelho
- Instituto de Estudos para Políticas de Saúde, São Paulo, Brazil
| | - Christopher Millett
- Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, London, UK
- NOVA National School of Public Health, Public Health Research Centre, Comprehensive Health Research Center, NOVA University Lisbon, Lisboa, Portugal
| | - Valeria Saraceni
- Health Surveillance Branch, Secretaria Municipal de Saúde do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Claudia Medina Coeli
- Instituto de Estudos em Saúde Coletiva, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Anete Trajman
- Programa de Pós-graduação em Clínica Médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Davide Rasella
- Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, London, UK
- Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, Brazil
| | - Betina Durovni
- Centro de Estudos Estratégicos, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Thomas Hone
- Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, London, UK
- Instituto de Estudos para Políticas de Saúde, São Paulo, Brazil
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Boolchandani H, Osborn R, Tiyyagura G, Sheares B, Chen L, Phatak UP, Puthenpura V, Elder RW, Lee S, Amster L, Langhan ML. Words Used in Letters of Recommendation for Pediatric Residency Applicants: Demographic Differences and Impact on Interviews. Acad Pediatr 2023; 23:1614-1619. [PMID: 36889506 DOI: 10.1016/j.acap.2023.02.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/20/2023] [Accepted: 02/27/2023] [Indexed: 03/10/2023]
Abstract
OBJECTIVE To describe differences in agentic (achievement) and communal (relationship) terms in letters of recommendation (LORs) for pediatric residency candidates by applicant and letter writer demographics and to examine if LOR language is associated with interview status. METHODS A random sample of applicant profiles and LORs submitted to one institution were analyzed from the 2020-21 Match. Letters of recommendation text was inputted into a customized natural language processing application which determined the frequency of agentic and communal words in each LOR. Neutral LORs were defined as having< 5% surplus of agentic or communal terms. RESULTS We analyzed 2094 LORs from 573 applicants: 78% were women, 24% were under-represented in medicine (URiM), and 39% were invited to interview. Most letter writers were women (55%) and of senior academic rank (49%). Overall, 53% of LORs were agency biased, 25% communal biased, and 23% neutral. There was no difference in agency and communally biased LORs by an applicant's gender (men 53% agentic vs women 53% agentic, P = .424), race or ethnicity (non-URiM 53% agentic vs URiM 51% agentic, P = .631). Male letter writers used significantly more agentic terms (8.5%) compared to women (6.7% agentic) or writers of both genders (3.1% communal) (P = .008). Applicants invited to interview were more likely to have a neutral LOR; however, no significant association existed between language and interview status. CONCLUSIONS No significant differences in language were found by applicant gender or race among pediatric residency candidates. Identifying potential biases within pediatric residency selection processes is important in creating an equitable approach to application review.
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Affiliation(s)
- Henna Boolchandani
- Department of Pediatrics (H Boolchandani), Yale New Haven Children's Hospital, CT
| | - Rachel Osborn
- Section of Pediatric Hospital Medicine (R Osborn), Department of Pediatrics at Yale University School of Medicine, New Haven, CT
| | - Gunjan Tiyyagura
- Section of Pediatric Emergency Medicine (G Tiyyagura and ML Langhan), Departments of Pediatrics and Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Beverley Sheares
- Section of Pediatric Pulmonology, Allergy, Immunology, and Sleep Medicine (B Sheares and L Chen), Department of Pediatrics at Yale University School of Medicine, New Haven, CT
| | - Laura Chen
- Section of Pediatric Pulmonology, Allergy, Immunology, and Sleep Medicine (B Sheares and L Chen), Department of Pediatrics at Yale University School of Medicine, New Haven, CT
| | - Uma P Phatak
- Section of Pediatric Gastroenterology and Hepatology (UP Phatak), Department of Pediatrics at Yale University School of Medicine, New Haven, CT
| | - Vidya Puthenpura
- Section of Pediatric Hematology and Oncology (V Puthenpura), Department of Pediatrics at Yale University School of Medicine, New Haven, CT
| | - Robert W Elder
- Section of Pediatric Cardiology (RW Elder), Department of Pediatrics at Yale University School of Medicine, New Haven, CT
| | - Seohyuk Lee
- Yale School of Medicine (S Lee), New Haven, CT
| | | | - Melissa L Langhan
- Section of Pediatric Emergency Medicine (G Tiyyagura and ML Langhan), Departments of Pediatrics and Emergency Medicine, Yale University School of Medicine, New Haven, CT.
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Trabilsy M, Roberts A, Ahmed T, Silver M, Manasseh DME, Andaz C, Borgen PI, Feinberg JA. Lack of Racial Diversity in Surgery and Pathology Textbooks Depicting Diseases of the Breast. J Surg Res 2023; 291:677-682. [PMID: 37562229 DOI: 10.1016/j.jss.2023.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 07/03/2023] [Accepted: 07/07/2023] [Indexed: 08/12/2023]
Abstract
INTRODUCTION The lack of racial diversity depicted in medical education texts may contribute to an implicit racial bias among clinicians. This bias influences outcomes, as familiarity with the various cutaneous manifestations of disease is essential to making an accurate diagnosis. To better understand the racial disparities in breast surgery, we sought to determine the extent of skin tone representation depicted in images of breast surgery and pathology textbooks. METHODS Textbooks were screened for color images of conditions with sufficient skin tissue present to assign the Fitzpatrick skin phototype (FSP). Figures were independently assigned an FP score (range: 1-6), and subdivided into "light skin" (FP 1-3) and "dark skin" (FP 4-6). Number of figures in each category and percentage of patients with each skin tone were calculated. RESULTS 557 figures were included. Among 12 textbooks reviewed, seven textbooks were from the discipline of surgery, while five were pathology-related. Textbook year of publication spanned from 1996 to 2018. Overall, 533 (95.7%) figures depicted patients with light skin color versus 24 (4.3%) with dark skin color. There was no association between FP score and year of textbook publication (P = 0.69). CONCLUSIONS Patient images in breast textbooks are overwhelmingly of light skin tones, excluding patients with darker skin tones. The dearth of images depicting dark skinned individuals did not improve over time. Inclusion of patients of color in future textbooks may help reduce racial disparities within breast cancer care.
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Affiliation(s)
- Maissa Trabilsy
- SUNY Downstate Health Sciences University, College of Medicine, Brooklyn, New York
| | - Arielle Roberts
- Maimonides Medical Center, Division of Breast Surgery, Brooklyn, New York
| | - Tahina Ahmed
- SUNY Downstate Health Sciences University, College of Medicine, Brooklyn, New York
| | - Michael Silver
- Maimonides Medical Center, Research Administration, Brooklyn, New York
| | | | - Charusheela Andaz
- Maimonides Medical Center, Division of Breast Surgery, Brooklyn, New York
| | - Patrick I Borgen
- Maimonides Medical Center, Division of Breast Surgery, Brooklyn, New York
| | - Joshua A Feinberg
- Maimonides Medical Center, Division of Breast Surgery, Brooklyn, New York.
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Dubov A, Krakower DS, Rockwood N, Montgomery S, Shoptaw S. Provider Implicit Bias in Prescribing HIV Pre-exposure Prophylaxis (PrEP) to People Who Inject Drugs. J Gen Intern Med 2023; 38:2928-2935. [PMID: 36964426 PMCID: PMC10593689 DOI: 10.1007/s11606-023-08040-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 01/10/2023] [Indexed: 03/26/2023]
Abstract
BACKGROUND Multiple HIV outbreaks among people who inject drugs (PWIDs) have occurred in the USA since 2015, highlighting the need for additional HIV prevention tools. Despite high levels of need, pre-exposure prophylaxis (PrEP) is drastically underutilized among PWIDs. Implicit bias toward PWID held by clinicians may impede PrEP scale-up among these underserved patients. This study examined how primary care providers' (PCPs) clinical decisions related to PrEP can be impacted by biases when the patient has a history of substance use. METHODS We conducted an online survey of PCPs (n = 208). The survey included the implicit association test (IAT) to assess unconscious attitudes toward PWIDs, direct questions regarding clinicians' explicit PWID attitudes, and an embedded experiment in which we systematically varied the risk behavior of a hypothetical patient and asked PCPs to make clinical judgments. RESULTS A minority (32%) of PCPs reported explicit PWID bias. The IAT indicated strong implicit PWID bias (meant IAT score = 0.59, p < .0001) among 88% of the sample. Only 9% of PCPs had no implicit or explicit PWID bias. PWID patients were judged as less likely to adhere to a PrEP regimen, less responsible, and less HIV safety conscious than heterosexual or gay male patients. Anticipated lack of adherence mediated PCPs' intent to prescribe PrEP to PWID. CONCLUSIONS PCPs' bias may contribute to PrEP being under-prescribed to PWID. Implicit and explicit PWID biases were common in our sample. This study illustrates the need to develop and test tailored interventions to decrease biases against PWID in primary care settings.
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Affiliation(s)
- Alex Dubov
- School of Behavioral Health, Loma Linda University, Loma Linda, CA USA
| | - Douglas S. Krakower
- Division of Infectious Diseases, Department of Population Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA USA
| | - Nicholas Rockwood
- School of Behavioral Health, Loma Linda University, Loma Linda, CA USA
| | | | - Steven Shoptaw
- Department of Family Medicine, University of California Los Angeles, Los Angeles, CA USA
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Abstract
Breast cancer treatment, timeliness of care, and clinical outcomes are inferior for patients of Black race and Hispanic ethnicity, and the origin of these inequities is multifactorial. Owing to aggregate reporting of data in the United States for patients of Asian, Native Hawaiian, and Pacific Islander ancestry, disparities within and across these groups are difficult to appreciate. In large part due to low prevalence, male breast cancer remains understudied, and treatment algorithms are primarily extrapolated from research conducted in female patients.
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Affiliation(s)
- Leisha C Elmore
- Department of Surgery, Penn Presbyterian Medical Center, University of Pennsylvania, Perelman School of Medicine, 51 North 39th Street, 266 Wright Sanders, Philadelphia, PA 19104, USA; Division of Breast Surgery, Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Silverstein 4, Philadelphia, PA 19104, USA. https://twitter.com/DrLolaFayanju
| | - Oluwadamilola M Fayanju
- Division of Breast Surgery, Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Silverstein 4, Philadelphia, PA 19104, USA.
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Jala S, Fry M, Elliott R. Cognitive bias during clinical decision-making and its influence on patient outcomes in the emergency department: A scoping review. J Clin Nurs 2023; 32:7076-7085. [PMID: 37605250 DOI: 10.1111/jocn.16845] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 06/16/2023] [Accepted: 07/31/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND An integral part of clinical practice is decision-making. Yet there is widespread acceptance that there is evidence of cognitive bias within clinical practice among nurses and physicians. However, how cognitive bias among emergency nurses and physicians' decision-making influences patient outcomes remains unclear. AIM The aim of this review was to systematically synthesise research exploring the emergency nurses' and physicians' cognitive bias in decision-making and its influence on patient outcomes. METHODS This scoping review was guided by the PRISMA Extension for Scoping Reviews. The databases searched included CINAHL, MEDLINE, Web of Science and PubMed. No date limits were applied. The Patterns, Advances, Gaps, Evidence for practice and Research recommendation (PAGER) framework was used to guide the discussion. RESULTS The review included 18 articles, consisting of 10 primary studies (nine quantitative and one qualitative) and eight literature reviews. Of the 18 articles, nine investigated physicians, five articles examined nurses, and four both physicians and nurses with sample sizes ranging from 13 to 3547. Six primary studies were cross-sectional and five used hypothetical scenarios, and one real-world assessment. Three were experimental studies. Twenty-nine cognitive biases were identified with Implicit bias (n = 12) most frequently explored, followed by outcome bias (n = 4). Results were inconclusive regarding the influence of biases on treatment decisions and patient outcomes. Four key themes were identified; (i) cognitive biases among emergency clinicians; (ii) measurement of cognitive bias; (iii) influence of cognitive bias on clinical decision-making; and (iv) association between emergency clinicians' cognitive bias and patient outcomes. CONCLUSIONS This review identified that cognitive biases were present among emergency nurses and physicians during clinical decision-making, but it remains unclear how cognitive bias influences patient outcomes. Further research examining emergency clinicians' cognitive bias is required. RELEVANCE TO CLINICAL PRACTICE Awareness of emergency clinicians' own cognitive biases may result to the provision of equity in care. NO PATIENT OR PUBLIC CONTRIBUTION IN THIS REVIEW We intend to disseminate the results through publication in a peer-reviewed journals and conference presentations.
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Affiliation(s)
- Sheila Jala
- Faculty of Health, School of Nursing and Midwifery, University of Technology Sydney, Sydney, New South Wales, Australia
- Neurology Department, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Margaret Fry
- Faculty of Health, School of Nursing and Midwifery, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Rosalind Elliott
- Faculty of Health, School of Nursing and Midwifery, University of Technology Sydney, Sydney, New South Wales, Australia
- Nursing and Midwifery Research Centre, Nursing and Midwifery Directorate, Northern Sydney Local Health District, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
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Pham TV, Doorley J, Kenney M, Joo JH, Shallcross AJ, Kincade M, Jackson J, Vranceanu AM. Addressing chronic pain disparities between Black and White people: a narrative review of socio-ecological determinants. Pain Manag 2023; 13:473-496. [PMID: 37650756 PMCID: PMC10621777 DOI: 10.2217/pmt-2023-0032] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 08/10/2023] [Indexed: 09/01/2023] Open
Abstract
A 2019 review article modified the socio-ecological model to contextualize pain disparities among different ethnoracial groups; however, the broad scope of this 2019 review necessitates deeper socio-ecological inspection of pain within each ethnoracial group. In this narrative review, we expanded upon this 2019 article by adopting inclusion criteria that would capture a more nuanced spectrum of socio-ecological findings on chronic pain within the Black community. Our search yielded a large, rich body of literature composed of 174 articles that shed further socio-ecological light on how chronic pain within the Black community is influenced by implicit bias among providers, psychological and physical comorbidities, experiences of societal and institutional racism and biomedical distrust, and the interplay among these factors. Moving forward, research and public-policy development must carefully take into account these socio-ecological factors before scaling up pre-existing solutions with questionable benefit for the chronic pain needs of Black individuals.
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Affiliation(s)
- Tony V Pham
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA 02114, USA
| | - James Doorley
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Martha Kenney
- Department of Anesthesiology, Duke University Medical Centre, Durham, NC 27710, USA
| | - Jin Hui Joo
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Amanda J Shallcross
- Wellness & Preventative Medicine, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Michael Kincade
- Center for Alzheimer's Research & Treatment, Massachusetts Alzheimer's Disease Research Centre, Boston, MA 02129, USA
| | - Jonathan Jackson
- Department of Neurology, Harvard Medical School, Boston, MA 02115, USA
| | - Ana-Maria Vranceanu
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA 02114, USA
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Palich R, Hentzien M, Hocqueloux L, Duvivier C, Allavena C, Huleux T, Delobel P, Makinson A, Rey D, Cuzin L. Country of birth is associated with antiretroviral therapy choice in treatment-naive persons with HIV in France. AIDS 2023; 37:1459-1466. [PMID: 37115905 DOI: 10.1097/qad.0000000000003588] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
OBJECTIVES We aimed to describe factors associated with the choice of first antiretroviral therapy (ART) in persons with HIV (PWH) in France, included the country of birth, as well as the time to undetectable viral load and treatment discontinuation. DESIGN Observational study conducted from the national Dat'AIDS prospectively collected database. METHODS We included all adults who started their first ART between 01 January 2014 and 31 December 2020, with a pretherapeutic plasma viral load (pVL) at least 400 copies/ml. Univariable and multivariable logistic regressions were used to analyze PWH characteristics driving to an integrase strand transfer inhibitors (INSTI)-based first prescribed regimen. We also analyzed time to first line discontinuation, and to a first undetectable pVL, using Kaplan-Meier model. RESULTS We analyzed data from 9094 PWH: 45% MSM, 27% women and 27% heterosexual men; 48% born abroad; 4.7 and 2.8% with concomitant hepatitis B and tuberculosis, respectively. INSTIs were prescribed as first-line therapy in 50% of PWH, which increased over time. Native French PWH were more likely to receive an INSTI-based regimen than PWH born abroad [adjusted prevalence ratio 1.47, 95% confidence interval (CI) 1.33-1.60], as were high pVL at diagnosis, hepatitis B or concomitant tuberculosis. Time before discontinuation of the first ART and reaching a first undetectable pVL was not different according to the place of birth. CONCLUSION Despite unrestricted access to INSTIs in France, independently from HIV disease parameters, PWH born abroad received INSTIs less frequently as a first regimen than those born in France. Qualitative data are needed to better understand physicians' prescribing practices.
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Affiliation(s)
- Romain Palich
- Sorbonne University, Infectious Diseases Department, Pitié-Salpêtrière hospital, AP-HP, Pierre Louis Epidemiology and Public Health institute (iPLESP), INSERM U1136, Paris
| | - Maxime Hentzien
- Infectious Diseases, Internal Medicine and Clinical Immunology Department, Centre Hospitalier Universitaire Robert Debré, Reims
| | - Laurent Hocqueloux
- Infectious Diseases Department, Centre Hospitalier Régional d'Orléans, Orléans
| | - Claudine Duvivier
- AP-HP-Necker Hospital, Infectious Diseases Department, Necker-Pasteur Infectiology Center, University Paris Cité, INSERM U1016, CNRS UMR8104, Institut Cochin, IHU Imagine, Institut Pasteur, Institut Pasteur Medical Center, Paris
| | | | - Thomas Huleux
- Infectious and Travel Diseases Department, Tourcoing University Hospital, Tourcoing
| | - Pierre Delobel
- Infectious and Tropical Diseases Department, Toulouse University Hospital, INSERM U1291, University of Toulouse Paul Sabatier, Toulouse
| | - Alain Makinson
- Infectious Diseases Department, University Hospital Montpellier, INSERM U1175, University of Montpellier, Montpellier
| | - David Rey
- HIV Infection Care Center, Strasbourg University Hospital, Strasbourg
| | - Lise Cuzin
- CERPOP, Toulouse University, INSERM UMR1295, UPS, Toulouse, France, Martinique University Hospital, Infectious and Tropical Diseases, Fort de France, France
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Hilario C, Louie-Poon S, Taylor M, Gill GK, Kennedy M. Racism in Health Services for Adolescents: A Scoping Review. INTERNATIONAL JOURNAL OF SOCIAL DETERMINANTS OF HEALTH AND HEALTH SERVICES 2023; 53:343-353. [PMID: 36927090 PMCID: PMC10315870 DOI: 10.1177/27551938231162560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 12/22/2022] [Accepted: 01/12/2023] [Indexed: 03/18/2023]
Abstract
Addressing racism within health systems and services is critical to addressing health vulnerabilities and promoting health equity for racialized populations. Currently, there is limited knowledge about the ways in which racism affects health services for adolescents. A scoping review was undertaken following the Joanna Briggs Institute Manual for Evidence Synthesis methodology and guided by the research questions: (1) What are the characteristics of the literature examining racism in health service use for adolescents? (2) What are the foci of the literature on systemic racism and health services for adolescents? A systematic literature search was conducted in April 2021 to identify all relevant published studies. The search identified 3049 unique articles, with a total of 13 articles included in this review. Multiple levels of racism were examined in the included articles across various health care settings. Five foci were identified: racism prevention, missed care, quality of care, racial bias, and experiences of racism. Our review indicates a current emphasis on interpersonal racism within this field of study, with emergent discussion of the impact of systemic racism. However, greater attention is needed that would investigate multiple forms of racism (institutional, interpersonal, internalized) in relation to specific contexts and adolescent populations.
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Affiliation(s)
- Carla Hilario
- School of Nursing, University of British Columbia Okanagan, Kelowna, British Columbia, Canada
| | - Samantha Louie-Poon
- School of Nursing, University of British Columbia Okanagan, Kelowna, British Columbia, Canada
| | - Mischa Taylor
- School of Nursing, University of British Columbia Okanagan, Kelowna, British Columbia, Canada
| | - Gurjeet K. Gill
- School of Nursing, University of British Columbia Okanagan, Kelowna, British Columbia, Canada
| | - Megan Kennedy
- School of Nursing, University of British Columbia Okanagan, Kelowna, British Columbia, Canada
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Green TL, Vu H, Swan LE, Luo D, Hickman E, Plaisime M, Hagiwara N. Implicit and explicit racial prejudice among medical professionals: updated estimates from a population-based study. THE LANCET REGIONAL HEALTH - AMERICAS 2023; 21:100489. [DOI: https:/doi.org/10.1016/j.lana.2023.100489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
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Ricci F, Torales J, Bener A, Castaldelli-Maia JM, Chumakov E, Bellomo A, Ventriglio A. Mental health of ethnic minorities: the role of racism. Int Rev Psychiatry 2023; 35:258-267. [PMID: 37267026 DOI: 10.1080/09540261.2023.2189951] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 03/08/2023] [Indexed: 06/03/2023]
Abstract
Racism and racial discrimination heavily impact on health and mental health of ethnic minorities. In this conceptual paper and narrative review, we aim to report on relevant evidence from the international literature describing the prevalence and the qualitative aspects of mental illness due to racism and ethnic- discrimination in different settings and populations. Some variables related to racism, such as cultural, institutional, interpersonal factors, as well as the concepts of perceived and internalised racism will be described and discussed. These are relevant characteristics in the explanatory model of the relationship between racism and mental health. Epidemiological data on the prevalence of depressive and psychotic symptoms as well as substance abuse/misuse among ethnic minorities in large catchment areas, such as United States and United Kingdom, will be represented. We conclude that anti-racism policies are essential in order to address racism and racial discrimination around the world. Pluralistic societies should be promoted in order to understand mental illnesses among ethnic and cultural minorities. Also, anti-racism programs should be delivered in the educational and health-care settings and their impact evaluated.
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Affiliation(s)
- Fabiana Ricci
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Julio Torales
- Department of Psychiatry, School of Medical Sciences, National University of Asunción, Asunción, Paraguay
| | - Abdulbari Bener
- Department of Biostatistics and Public Health, Schools of Medicine, Dentistry and Pharmacy, Istanbul Medipol University, İstanbul, Turkey
| | - João Mauricio Castaldelli-Maia
- Department of Neuroscience, Medical School, Fundação do ABC, Santo André, Brazil
- Department of Psychiatry, Medical School, University of São Paulo, São Paulo, Brazil
| | - Egor Chumakov
- Department of Psychiatry and Addiction, St. Petersburg State University, St. Petersburg, Russia
| | - Antonello Bellomo
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Antonio Ventriglio
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
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Hurd NM, Young AS. Introduction to the Special Issue: Advancing Racial Justice in Clinical Child and Adolescent Psychology. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY : THE OFFICIAL JOURNAL FOR THE SOCIETY OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY, AMERICAN PSYCHOLOGICAL ASSOCIATION, DIVISION 53 2023; 52:311-327. [PMID: 37141558 PMCID: PMC10213141 DOI: 10.1080/15374416.2023.2202255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Relative to White youth, racially and ethnically marginalized youth in the U.S. are less likely to initiate treatment, stay in treatment, and receive adequate care. This special issue attends to racial injustice in clinical child and adolescent psychology. While numerous factors drive these racial disparities, this special issue focuses specifically on opportunities and responsibilities we have as mental health providers, teachers, mentors, researchers, and gatekeepers to make our field more racially just. In this introduction to the special issue, we review barriers and solutions across multiple contexts including structural, institutional, and practice-based. We also discuss challenges and opportunities to diversify our field and increase the representation of racially and ethnically marginalized practitioners and scholars in clinical child and adolescent psychology. We then briefly review the special issue articles and make final recommendations for how to move the field forward.
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Affiliation(s)
| | - Andrea S Young
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine
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Green TL, Vu H, Swan LE, Luo D, Hickman E, Plaisime M, Hagiwara N. Implicit and explicit racial prejudice among medical professionals: updated estimates from a population-based study. LANCET REGIONAL HEALTH. AMERICAS 2023; 21:100489. [PMID: 37179794 PMCID: PMC10172896 DOI: 10.1016/j.lana.2023.100489] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/02/2023] [Accepted: 03/23/2023] [Indexed: 05/15/2023]
Abstract
Background Prior research provides evidence of implicit and explicit anti-Black prejudice among US physicians. However, we know little about whether racialized prejudice varies among physicians and non-physician healthcare workers relative to the general population. Methods Using ordinary least squares models and data from Harvard's Project Implicit (2007-2019), we assessed the associations between self-reported occupational status (physician, non-physician healthcare worker) and implicit (N = 1,500,268) and explicit prejudice (N = 1,429,677) toward Black, Arab-Muslim, Asian, and Native American populations, net of demographic characteristics. We used STATA 17 for all statistical analyses. Findings Physicians and non-physician healthcare workers exhibited more implicit and explicit anti-Black and anti-Arab-Muslim prejudice than the general population. After controlling for demographics, these differences became non-significant for physicians but remained for non-physician healthcare workers (β = 0.027 and 0.030, p < 0.01). Demographic controls largely explained anti-Asian prejudice among both groups, and physicians and non-physician healthcare workers exhibited comparatively lower (β = -0.124, p < 0.01) and similar levels of anti-Native implicit prejudice, respectively. Finally, white non-physician healthcare workers exhibited the highest levels of anti-Black prejudice. Interpretation Demographic characteristics explained racialized prejudice among physicians, but not fully among non-physician healthcare workers. More research is needed to understand the causes and consequences of elevated levels of prejudice among non-physician healthcare workers. By acknowledging implicit and explicit prejudice as important reflections of systemic racism, this study highlights the need to understand the role of healthcare providers and systems in generating health disparities. Funding UW-Madison Centennial Scholars Program, Society of Family Planning Research Fund, UW Center for Demography and Ecology, the County Health Rankings and Roadmaps Program and the National Institutes of Health (NIH).
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Affiliation(s)
- Tiffany L. Green
- Department of Population Health Sciences, University of Wisconsin–Madison, Madison, WI, USA
| | - Hoa Vu
- Department of Population Health Sciences, University of Wisconsin–Madison, Madison, WI, USA
| | - Laura E.T. Swan
- Department of Population Health Sciences, University of Wisconsin–Madison, Madison, WI, USA
| | - Dian Luo
- Department of Population Health Sciences, University of Wisconsin–Madison, Madison, WI, USA
| | - Ellen Hickman
- Department of Population Health Sciences, University of Wisconsin–Madison, Madison, WI, USA
| | - Marie Plaisime
- FXB Center for Health & Human Rights, Harvard H.T. Chan School of Public Health, Boston, MA, USA
| | - Nao Hagiwara
- Department of Psychology, Virginia Commonwealth University, Richmond, VA, USA
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Matabele MM, Haider SF, Wood Matabele KL, Merchant AM, Chokshi RJ. The Mediating Effect of Operative Approach on Racial Disparities in Bariatric Surgery Complications. J Surg Res 2023; 289:42-51. [PMID: 37084675 DOI: 10.1016/j.jss.2023.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 03/10/2023] [Accepted: 03/19/2023] [Indexed: 04/23/2023]
Abstract
INTRODUCTION A laparoscopic approach to bariatric surgeries confers a favorable side-effect profile as compared to an open approach. However, literature regarding the independent association of race with access to and postoperative outcomes in laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (GS) is scarce. MATERIALS AND METHODS All RYGB and GS cases recorded in American College of Surgeons National Quality Improvement Program data from 2012 to 2020 were subjected to propensity score matching to assess the independent association between Black self-identified race on access to a laparoscopic approach and postoperative complications. Finally, a series of logistic regressions enabled evaluation of the mediating effect of operative approach on racial disparities in postoperative complications. RESULTS 55,846 cases of RYGB and 94,209 cases of GS were identified. Following propensity score matching, logistic regression identified Black race as an independent predictor of open approach to RYGB (P < 0.001) and GS (P = 0.019). Black patients had increased incidence of any, minor and severe postoperative complications and unplanned readmissions in both RYGB (P < 0.001, P < 0.001, P = 0.0412, and P < 0.001, respectively) and GS (P < 0.001, P < 0.001, P = 0.0037, and P < 0.001, respectively). Open approach to RYGB was identified as a partial mediator of the independent association between Black race and any complication, minor complications, and unplanned readmission. CONCLUSIONS This methodology identified racial disparities in complications following RYGB and GS. Interestingly, reduced access to a laparoscopic approach mediated racial disparities in complications following RYGB but not GS. Further research might elucidate upstream determinants of health that catalyze these disparities.
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Affiliation(s)
- Mario M Matabele
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
| | - Syed F Haider
- General Surgery Minimally Invasive and Robotic Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | | | - Aziz M Merchant
- General Surgery Minimally Invasive and Robotic Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Ravi J Chokshi
- Division of Surgical Oncology, Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
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Edwards NM, Isik-Ercan Z, Lu HT, Fall M, Sebti L. "Do the Best You Can with Resources You Have to Offer": Community stakeholder views on supporting immigrant families. JOURNAL OF COMMUNITY PSYCHOLOGY 2023; 51:837-859. [PMID: 36413594 DOI: 10.1002/jcop.22970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 11/04/2022] [Accepted: 11/07/2022] [Indexed: 06/16/2023]
Abstract
First and second-generation immigrant families of young children in the United States face potential challenges that may be mitigated with stakeholder support in their communities. We examined self-reported views and behaviors among professionals (n = 76) working with families in a mid-Atlantic urban community, and whether these views correlated with demographic factors. Over half of respondents were not able/willing to report the number of immigrant families served and over half believed immigrant parents are less likely to advocate for themselves or their child. Participants were fairly split in seeking advice from others and comfort in talking with immigrant families about their culture/needs. It is essential to assess stakeholders' views on perceived roles, roadblocks, and desired supports. This analysis informs efforts to work more collaboratively with community partners to improve outreach to immigrant families during those formative years in a child's development. Implications for research, practice, and policy are discussed.
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Affiliation(s)
- Nicole Megan Edwards
- Department of Interdisciplinary and Inclusive Education, College of Education, Rowan University, Glassboro, New Jersey, USA
| | - Zeynep Isik-Ercan
- Department of Interdisciplinary and Inclusive Education, College of Education, Rowan University, Glassboro, New Jersey, USA
| | - Huan-Tang Lu
- Department of Educational Services and Leadership, College of Education, Rowan University, Glassboro, New Jersey, USA
| | - Madjiguene Fall
- School of Curriculum & Teaching, College of Education, Kean University, Union, New Jersey, USA
| | - Latifa Sebti
- Doctoral Candidate, PhD in Education: Special Education Concentration, College of Education, Rowan University, Glassboro, New Jersey, USA
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Hagiwara N, Duffy C, Quillin J. Implicit and explicit racial prejudice and stereotyping toward Black (vs. White) Americans: The prevalence and variation among genetic counselors in North America. J Genet Couns 2023; 32:397-410. [PMID: 36341692 PMCID: PMC10168592 DOI: 10.1002/jgc4.1648] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 09/27/2022] [Accepted: 10/08/2022] [Indexed: 11/09/2022]
Abstract
Research has shown that patient experiences and outcomes of genetic counseling are not equitable across racial categories, disadvantaging Black patients relative to White patients. One major factor contributing to such racial disparities might be genetic counselor racial bias. The present study examined the prevalence of and variation in racial bias toward Black (vs. White) Americans among genetic counselors in North America. This study extends the current literature of racial disparities in experiences and outcomes of genetic counseling by distinguishing prejudice (negative feelings or attitudes) and stereotyping (beliefs) at the implicit and explicit levels as well as by including both certified genetic counselors and genetic counseling trainees. Two-hundred and fifteen genetic counselors (107 genetic counselors Board-certified by the American Board of Genetic Counseling, 108 genetic counseling trainees from Accreditation Council for Genetic Counseling accredited programs) completed four measures in a random order: the Race Implicit Association Test (IAT, for implicit prejudice), feeling thermometer (for explicit prejudice), the Medical Cooperativeness IAT (for implicit stereotyping), and a self-report measure of explicit stereotypes (for explicit stereotyping). On average, genetic counselors (both certified genetic counselors and genetic counseling trainees) were slightly to moderately in favor of White Americans over Black Americans at the implicit level. They were also slightly more likely to associate "medically cooperative" stereotypes with White Americans more than Black Americans implicitly. In contrast, genetic counselors, on average, did not display either explicit prejudice or explicit negative stereotyping, which may reflect social desirability concerns among genetic counselors. However, genetic counselors as a group strongly endorsed stereotypes related to mistrust (mistrustful of the healthcare system, skeptical of genetic testing, mistrustful of genetic counselors) to be more true for Black (vs. White) Americans. Finally, our study revealed relatively large variability in each type of bias across genetic counselors. Future research should examine how such variability in each type of bias is associated with patient experiences and outcomes of genetic counseling.
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Affiliation(s)
- Nao Hagiwara
- Department of Psychology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Conor Duffy
- Department of Psychology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - John Quillin
- Department of Pediatrics, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
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LaDonna KA, Kahlke R, Scott I, van der Goes T, Hubinette M. Grappling with key questions about assessment of the Health Advocate role. CANADIAN MEDICAL EDUCATION JOURNAL 2023; 14:80-89. [PMID: 36998507 PMCID: PMC10042793 DOI: 10.36834/cmej.73878] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Introduction Although the CanMEDS framework sets the standard for Canadian training, health advocacy competence does not appear to factor heavily into high stakes assessment decisions. Without forces motivating uptake, there is little movement by educational programs to integrate robust advocacy teaching and assessment practices. However, by adopting CanMEDS, the Canadian medical education community endorses that advocacy is required for competent medical practice. It's time to back up that endorsement with meaningful action. Our purpose was to aid this work by answering the key questions that continue to challenge training for this intrinsic physician role. Methods We used a critical review methodology to both examine literature relevant to the complexities impeding robust advocacy assessment, and develop recommendations. Our review moved iteratively through five phases: focusing the question, searching the literature, appraising and selecting sources, and analyzing results. Results Improving advocacy training relies, in part, on the medical education community developing a shared vision of the Health Advocate (HA) role, designing, implementing, and integrating developmentally appropriate curricula, and considering ethical implications of assessing a role that may be risky to enact. Conclusion Changes to assessment could be a key driver of curricular change for the HA role, provided implementation timelines and resources are sufficient to make necessary changes meaningful. To truly be meaningful, however, advocacy first needs to be perceived as valuable. Our recommendations are intended as a roadmap for transforming advocacy from a theoretical and aspirational value into one viewed as having both practical relevance and consequential implications.
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Affiliation(s)
| | | | - Ian Scott
- University of British Columbia, British Columbia, Canada
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Roach P, Ruzycki SM, Hernandez S, Carbert A, Holroyd-Leduc J, Ahmed S, Barnabe C. Prevalence and characteristics of anti-Indigenous bias among Albertan physicians: a cross-sectional survey and framework analysis. BMJ Open 2023; 13:e063178. [PMID: 36813494 PMCID: PMC9950908 DOI: 10.1136/bmjopen-2022-063178] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
OBJECTIVE Recent deaths of Indigenous patients in the Canadian healthcare system have been attributed to structural and interpersonal racism. Experiences of interpersonal racism by Indigenous physicians and patients have been well characterised, but the source of this interpersonal bias has not been as well studied. The aim of this study was to describe the prevalence of explicit and implicit interpersonal anti-Indigenous biases among Albertan physicians. DESIGN AND SETTING This cross-sectional survey measuring demographic information and explicit and implicit anti-Indigenous biases was distributed in September 2020 to all practising physicians in Alberta, Canada. PARTICIPANTS 375 practising physicians with an active medical licence. OUTCOMES Explicit anti-Indigenous bias, measured by two feeling thermometer methods: participants slid an indicator on a thermometer to indicate their preference for white people (full preference is scored 100) or Indigenous people (full preference, 0), and then participants indicated how favourably they felt toward Indigenous people (100, maximally favourable; 0, maximally unfavourable). Implicit bias was measured using an Indigenous-European implicit association test (negative scores suggest preference for European (white) faces). Kruskal-Wallis and Wilcoxon rank-sum tests were used to compare bias across physician demographics, including intersectional identities of race and gender identity. MAIN RESULTS Most of the 375 participants were white cisgender women (40.3%; n=151). The median age of participants was 46-50 years. 8.3% of participants felt unfavourably toward Indigenous people (n=32 of 375) and 25.0% preferred white people to Indigenous people (n=32 of 128). Median scores did not differ by gender identity, race or intersectional identities. White cisgender men physicians had the greatest implicit preferences compared with other groups (-0.59 (IQR -0.86 to -0.25); n=53; p<0.001). Free-text responses discussed 'reverse racism' and expressed discomfort with survey questions addressing bias and racism. CONCLUSIONS Explicit anti-Indigenous bias was present among Albertan physicians. Concerns about 'reverse racism' targeting white people and discomfort discussing racism may act as barriers to addressing these biases. About two-thirds of respondents had implicit anti-Indigenous bias. These results corroborate the validity of patient reports of anti-Indigenous bias in healthcare and emphasise the need for effective intervention.
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Affiliation(s)
- Pamela Roach
- Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shannon M Ruzycki
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Santanna Hernandez
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Amanda Carbert
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Sofia Ahmed
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Cheryl Barnabe
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
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Williams JH, Tajeu GS, Stepanikova I, Juarez LD, Agne AA, Stone J, Cherrington AL. Perceived discrimination in primary care: Does Payer mix matter? J Natl Med Assoc 2023; 115:81-89. [PMID: 36566138 PMCID: PMC10040422 DOI: 10.1016/j.jnma.2022.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 09/22/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Previous literature has explored patient perceptions of discrimination by race and insurance status, but little is known about whether the payer mix of the primary care clinic (i.e., that is majority public insurance vs. majority private insurance clinics) influences patient perceptions of race- or insurance-based discrimination. METHODS Between 2015-2017, we assessed patient satisfaction and perceived race- and insurance-based discrimination using a brief, anonymous post-clinic visit survey. RESULTS Participants included 3,721 patients from seven primary care clinics-three public clinics and four private clinics. Results from unadjusted logistic regression models suggest higher overall reports of race- and insurance-based discrimination in public clinics compared with private clinics. In mulvariate analyses, increasing age, Black race, lower education and Medicaid insurance were associated with higher odds of reporting race- and insurance-based discrimination in both public and private settings. CONCLUSION Reports of race and insurance discrimination are higher in public clinics than private clinics. Sociodemographic variables, such as age, Black race, education level, and type of insurance also influence reports of race- and insurance-based discrimination in primary care.
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Affiliation(s)
- Jessica H Williams
- Department of Health Services Administration, School of Health Professions. University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Gabriel S Tajeu
- Department of Health Services Administration and Policy, Temple University, Philadelphia, PA, USA
| | - Irena Stepanikova
- Department of Sociology, University of Alabama at Birmingham and Research Centre for Toxic Compounds in the Environment, Masaryk University, Czech Republic, Birmingham, AL, USA
| | - Lucia D Juarez
- Division of Preventive Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - April A Agne
- Division of Preventive Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jeff Stone
- Department of Psychology, University of Arizona, Tucson, AZ
| | - Andrea L Cherrington
- Division of Preventive Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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