The C2DREAM framework: Investigating the structural mechanisms undergirding racial health inequities

Racism shapes the distribution of the social determinants of health (SDoH) along racial lines. Racism determines the environments in which people live, the quality of housing, and access to healthcare. Extensive research shows racism in its various forms negatively impacts health status, yet few studies and interventions seriously interrogate the role of racism in impacting health. The C2DREAM framework illuminates how exposure to racism, in multiple forms, connects to cardiovascular disease, hypertension, and obesity. The goal of the C2DREAM framework is to guide researchers to critically think about and measure the role of racism across its many levels of influence to better elucidate the ways it contributes to persistent health inequities. The conceptual framework highlights the interconnectedness between forms of racism, SDoH, and the lifecourse to provide a greater context to individual health outcomes. Utilizing this framework and critically contending with the effects of racism in its multiple and cumulative forms will lead to better research and interventions.

Comparisons of Explicit Weight Bias Across Common Clinical Specialties of US Resident Physicians

BACKGROUND

Patients with high body weight are persistently stigmatized in medical settings, with studies demonstrating that providers endorse negative stereotypes of, and have lower regard for, higher-weight patients. Very little is known about how this weight bias varies across specialties.

OBJECTIVE

The purpose of this study is to examine how explicit weight bias varies between resident providers among sixteen of the largest residency specialties in the USA. The identification of these differences will guide the prioritization and targeting of interventions.

DESIGN

The current study utilized cross-sectional, observational data.

PARTICIPANTS

Forty-nine allopathic medical schools were recruited to participate in this national, longitudinal study. The current study utilized data from 3267 trainees in Year 2 of Residency among those who specialized in one of the most common sixteen residency programs in 2016.

MAIN MEASURES

Participants reported demographic information and residency specialties and completed three sets of measures pertaining to explicit weight bias.

KEY RESULTS

A significant minority (13-48%) of residents reported slight-to-strong agreement with each anti-fat statement. There was a significant relationship between residency specialty and anti-fat blame (F(15, 3189 = 12.87, p < .001), η2 = .06), anti-fat dislike (F(15, 3189 = 7.01, p < .001), η2 = .03), and attitudes towards obese patients (F(15, 3208 = 17.78, p < .001), η2 = .08). Primary care residents (e.g., family medicine, pediatrics) consistently reported lower levels of weight bias than those in specialty programs (e.g., orthopedic surgery, anesthesiology).

CONCLUSIONS

This study is the first to report on weight bias in a large, heterogeneous sample of US resident physicians. Problematic levels of weight bias were found in all specialties, with residents in specialty programs generally reporting more bias than those in primary care residencies. Future research should examine which factors contribute to these differences to guide intervention.

Psychological reactance, misinformation, and distrust: A mixed methods analysis of COVID-19 vaccine uptake

Background

Assessing perceptions of the COVID-19 vaccines is essential for understanding vaccine hesitancy and for improving uptake during public health emergencies. In the complicated landscape of COVID-19 vaccine mandates and rampant misinformation, many individuals faced challenges during vaccination decision-making. The purpose of our mixed methods study is to elucidate factors affecting vaccine decision-making and to highlight the discourse surrounding the COVID-19 vaccines in diverse and underserved communities.

Methods

This mixed methods study was conducted in Arizona, Florida, Minnesota, and Wisconsin between March and November 2021, combining a cross-sectional survey (n = 3593) and focus groups (n = 47).

Results

The groups least likely to report receiving a vaccination were non-Hispanic Whites, Indigenous people, males, and those with moderate socioeconomic status (SES). Those indicating high and low SES reported similar vaccination uptake. Focus group data highlighted resistance to mandates, distrust, misinformation, and concerns about the rapid development surrounding the COVID-19 vaccines. Psychological reactance theory posits that strongly persuasive messaging and social pressure can be perceived as a threat to freedom, encouraging an individual to take action to restore that freedom.

Conclusion

Our findings indicate that a subsection of participants felt pressured to get the vaccine, which led to weaker intentions to vaccinate. These results suggest that vaccine rollout strategies should be reevaluated to improve and facilitate informed decision-making.

Patient perceptions of body mass index restrictions limiting fertility care for women with high body mass index

RESEARCH QUESTION

What is the patient experience of women with high body mass index (BMI) with BMI restrictions that limit fertility care?

DESIGN

Qualitative study using in-depth, semi-structured interview methodology. Interview transcripts were analysed for iterative themes in accordance with principles of grounded theory.

RESULTS

Forty women with a BMI of 35 kg/m2 or higher with scheduled or completed appointment at the Reproductive Endocrinology and Infertility (REI) clinic completed an interview. Most participants experienced BMI restrictions as unjust. Many perceived that BMI restrictions on fertility care may be medically justified and were in support of weight loss discussions to improve chances of pregnancy; however, several argued that they should have autonomy to commence treatment following an individualized risk assessment. Participants offered recommendations to improve discussion of BMI restrictions and weight loss, including framing the conversation as supportive of their reproductive goals and offering proactive referral to weight loss support to prevent the perception that BMI is a categorical exclusion to future fertility care.

CONCLUSIONS

Participant experiences highlight a need for enhanced strategies for communicating BMI restrictions and weight loss recommendations in ways that are perceived to be supportive of patients' fertility goals without further contributing to weight bias and stigma experienced in medical settings. Opportunities for training to mitigate experiences of weight stigma may be beneficial for clinical and non-clinical staff. Evaluation of BMI policies should be undertaken within the context of clinic policies that permit or prohibit fertility care for other high-risk groups.

The impact of neighborhoods and friendships on interracial anxiety among medical students and residents: A report from the medical student CHANGES study

OBJECTIVE

To examine the experience of interracial anxiety among health professionals and how it may affect the quality of their interactions with patients from racially marginalized populations. We explored the influence of prior interracial exposure-specifically through childhood neighborhoods, college student bodies, and friend groups-on interracial anxiety among medical students and residents. We also examined whether levels of interracial anxiety change from medical school through residency.

DATA SOURCE

Web-based longitudinal survey data from the Medical Student Cognitive Habits and Growth Evaluation Study.

STUDY DESIGN

We used a retrospective longitudinal design with four observations for each trainee. The study population consisted of non-Black US medical trainees surveyed in their 1st and 4th years of medical school and 2nd and 3rd years of residency. Mixed effects longitudinal models were used to assess predictors of interracial anxiety and assess changes in interracial anxiety scores over time.

PRINCIPAL FINDINGS

In total, 3155 non-Black medical trainees were followed for 7 years. Seventy-eight percent grew up in predominantly White neighborhoods. Living in predominantly White neighborhoods and having less racially diverse friends were associated with higher levels of interracial anxiety among medical trainees. Trainees' interracial anxiety scores did not substantially change over time; interracial anxiety was highest in the 1st year of medical school, lowest in the 4th year, and increased slightly during residency.

CONCLUSIONS

Neighborhood and friend group composition had independent effects on interracial anxiety, indicating that premedical racial socialization may affect medical trainees' preparedness to interact effectively with diverse patient populations. Additionally, the lack of substantial change in interracial anxiety throughout medical training suggests the importance of providing curricular tools and structure (e.g., instituting interracial cooperative learning activities) to foster the development of healthy interracial relationships.

Patient and Health Care Professional Perspectives on Stigma in Integrated Behavioral Health: Barriers and Recommendations

PURPOSE

Stigma related to mental health is well documented and a major barrier to using mental and physical health care. Integrated behavioral health (IBH) in primary care, in which behavioral/mental health care services are located within a primary care setting, may reduce the experience of stigma. The purpose of this study was to assess the opinions of patients and health care professionals about mental illness stigma as a barrier to engagement with IBH and to gain insight into strategies to reduce stigma, encourage discussion of mental health, and increase uptake of IBH care.

METHODS

We conducted semistructured interviews with 16 patients referred to IBH in a prior year and 15 health care professionals (12 primary care physicians and 3 psychologists). Interviews were transcribed and inductively coded separately by 2 coders for common themes and subthemes under the topic headings of barriers, facilitators, and recommendations.

RESULTS

We identified 10 converging themes from interviews with patients and the health care professionals, representing important complementary perspectives, with respect to barriers, facilitators, and recommendations. Barriers included professionals, families, and the public as sources of stigma, as well as self-stigma or avoidance, or internalizing negative stereotypes. Facilitators and recommendations included normalizing discussion of mental health and mental health care-seeking action, using patient-centered and empathetic communication strategies, sharing by health care professionals of their own experiences, and tailoring the discussion of mental health to patients' preferred understanding.

CONCLUSIONS

Health care professionals can help reduce perceptions of stigma by having conversations with patients that normalize mental health discussion, use patient-centered communication, promote professional self-disclosure, and are tailored to patients' preferred understanding.

Dismantling weight stigma in eating disorder treatment: Next steps for the field

The authors posit current guidelines and treatment for eating disorders (EDs) fail to adequately address, and often perpetuate, weight stigma. The social devaluation and denigration of higher-weight individuals cuts across nearly every life domain and is associated with negative physiological and psychosocial outcomes, mirroring the harms attributed to weight itself. Maintaining focus on weight in ED treatment can intensify weight stigma among patients and providers, leading to increased internalization, shame, and poorer health outcomes. Stigma has been recognized as a fundamental cause of health inequities. With no clear evidence that the proposed mechanisms of ED treatment effectively address internalized weight bias and its association with disordered eating behavior, it is not hard to imagine that providers' perpetuation of weight bias, however unintentional, may be a key contributor to the suboptimal response to ED treatment. Several reported examples of weight stigma in ED treatment are discussed to illustrate the pervasiveness and insidiousness of this problem. The authors contend weight management inherently perpetuates weight stigma and outline steps for researchers and providers to promote weight-inclusive care (targeting health behavior change rather than weight itself) as an alternative approach capable of addressing some of the many social injustices in the history of this field.

Patient Satisfaction Scores Impact Pediatrician Practice Patterns, Job Satisfaction, and Burnout

Patient satisfaction (PS) surveying has become a commonly used measure of physician performance, but little is known about the impact on pediatricians. To investigate our hypothesis that PS surveys negatively impact pediatricians, we conducted a survey at an academic children's medical center. Of 155 eligible physicians, 115 responded (response rate 74%). Two-thirds (68%) did not find the PS score report useful and 88% did not feel that PS scores accurately reflect the physician's clinical ability. A third reported ordering tests, medications, or consultations due to pressure for higher PS scores. In addition, one-third agreed that PS surveys contribute to burnout and make it difficult to practice meaningful medicine. Overall, PS score reporting has a negative impact on pediatricians, especially those who are female, BIPOC (Black, Indigenous, and People of color), subspecialists, younger, and attended non-US medical schools. Further investigation into improved methods for providing feedback to pediatric physicians is warranted.

The Interplay Between Group Identity, Suicidality, and Bullying in Midwestern Middle School Youth, 18-42

Bullying peaks in middle school and is a risk factor for negative mental health outcomes, including suicidality. Suicide rates are higher in nonmetropolitan/rural areas and for American Indian/Alaska Natives compared to other racial/ethnic groups. Stigma-related bullying, a type of interpersonal discrimination, is increasingly considered an important driver of peer victimization. This study centers on the group identity characteristics of race/ethnicity, weight status, and sex to explore how school-based and electronic-bullying victimization mediate suicidality amongst a cohort of middle school students in North Dakota. Bivariate, multivariate, and structural equation modeling were performed using data from the 2015 North Dakota Middle School Youth Risk Behavior Survey. Minoritized race/ethnicity, very overweight, and female students all experienced statistically higher suicidality than comparison groups, mediated in some instances by bullying. Group identity, stigma, and discrimination may influence suicidality in North Dakota middle school youth. More information is needed on stigma and discrimination, including intersections of identity, as drivers of bullying and suicidality in minoritized youth in nonmetropolitan/rural areas.

Key Stakeholder Perspectives of Community Engagement Efforts and the Impact of the Covid-19 Pandemic

Introduction:

The COVID-19 pandemic has disproportionally affected historically marginalized populations and their access to resources and healthcare. In times of crisis, authentic community engagement is more important than ever. This study was Phase 1 of a larger 3-phase study to conduct timely community-engaged research with community members to understand the disproportionate impact of COVID-19 on historically underserved communities. The objective of this work was to conduct key informant (KI) interviews (1) to understand community organizations perspectives about the role that large academic health centers play as they interface with community organizations to support their work, (2) to leverage KI’s expertise to identify needs and assets within the community, and (3) to inform both Phase 2 (focus group qualitative research) and Phase 3 (survey) of the broader study.

Methods:

A total of 24 key informants were identified through purposeful sampling and one-on-one semi-structured interviews were conducted across 4 states using video conferencing.

Results:

Barriers to access and lack of transparency were highlighted as major issues requiring reform—in particular, aggressive billing practices and insurance barriers exacerbated local distrust of medical institutions. KIs recognized the health institution’s support for testing and vaccination during the COVID-19 pandemic, but noted other significant gaps in care, especially regarding mental health support. Although communication with the health institution was consistent for some KIs, others experienced unsustained communication efforts that hindered cooperation and relationship building.

Conclusions:

Leaders in the community as key stakeholders can provide unique insights into the challenges and potential solutions required to promote health equity, and foster understanding between local communities and healthcare institutions.

The role of weight stigma in weight regain in bariatric surgery

Obesity is highly stigmatized, and individuals who undergo bariatric surgery are subject not only to weight stigma, but also to stigma related to the procedure itself. Patients lost to follow-up after surgery make estimating the amount of regain occurring after surgery difficult, and often patients fail to follow up due the shame of weight regain. Patients report difficulty following the diet necessary to maintain weight loss. Additionally, when they seek support after surgery, they often encounter stigmatizing messaging related to weight. Weight bias internalization, weight stigma, and stigma about having the surgery all contribute to feelings of social isolation, disordered eating, and reduced motivation to engage in physical activity. In this chapter, we present evidence for the impact of stigma on bariatric surgery outcomes and discuss the behavioral, physiological, and emotional processes that contribute to weight regain.

Testing a Self-Affirmation Intervention for Improving the Psychosocial Health of Black and White Medical Students in the US

Self-affirmation interventions have been shown to mitigate the negative psychological effects of stereotype threat on Black students in secondary and undergraduate education. However, there is currently limited research testing whether Black students in medical schools may also experience the negative influences of stereotype threat. Until now, it has been unclear whether Black (vs. White) students experience a lower sense of belonging in medical school and whether they can benefit from self-affirmation interventions during medical training. With a longitudinal field experiment, we tested (a) whether Black (vs. White) medical students in the US experience decrements in psychological well-being (i.e., fatigue, depression, anxiety), sense of belonging, perceived residency competitiveness, and residency goal stability; and (b) the extent to which a self-affirmation intervention would ameliorate any observed disparities in these outcomes for Black students. With a sample of 234 Black and 182 White medical students across 50 schools in the US, we found that Black students tended to report more fatigue and less belonging than White students; however, the self-affirmation intervention did not significantly influence students' fatigue, depression, anxiety, or belonging. Unexpectedly, Black students in the self-affirmation (vs. control) condition reported lower perceived competitiveness for residency. White students' perceived competitiveness for residency was unaffected by the intervention. Exploratory analyses revealed that Black (vs. White) students were less likely to indicate stable residency goals over time, which may be an indication of threat; however, this racial gap was eliminated with the intervention. We discuss the plausible reasons for these findings and provide recommendations for future work in this area.

A model of weight-based stigma in health care and utilization outcomes: Evidence from the learning health systems network

Objective

Obesity is stigmatized and people with obesity report experiencing stigmatizing situations when seeking health care. The implications of these experiences are not well understood. This study tests an indirect effects model of negative care experiences as an intermediate variable between obesity and care avoidance/utilization and switching primary care doctors.

Methods

A survey was completed by 2380 primary care patients in the Learning Health Systems Network (LHSNet) Clinical Data Research Network with a BMI >25 kg/m². Measures included scales assessing stigmatizing situations, perceived patient-centered communication, perceived respect, having delayed needed care, and having looked for a new primary doctor in the past 12 months. Sequential and serial indirect effects of care experiences and respect in the association between BMI and care utilization outcomes was modeled.

Results

The hypothesized model was supported by findings. The associations between BMI and delaying needed care (OR = 1.06, p < 0.001) and attempting to switch primary doctors (OR = 1.02, p = 0.04) was mediated by both stigmatizing situations experienced in a health care context and lower patient-centered communication. Lower perceived respect mediated the association between care experiences and utilization outcomes.

Conclusions

People with higher BMIs may avoid care or switch doctors as a result of stigmatizing experiences and poor communication with doctors. These outcomes may contribute to morbidity in people with obesity if they delay or avoid care for health concerns when symptoms first present.

The role of weight bias and role-modeling in medical students' patient-centered communication with higher weight standardized patients

OBJECTIVE

Patients with obesity may experience less patient-centered care. We assessed whether medical students' implicit/explicit weight-related attitudes and perceptions of normative attitudes are associated with patient-centered care for patients with obesity.

METHODS

Third and fourth year medical students (N = 111) at one medical school completed a survey and participated in a patient care scenario with a standardized patient with obesity. Encounters were coded for patient-centered behavior. Predictors of patient-centered behaviors were assessed.

RESULTS

Student perceptions that negative attitudes about patients with obesity are normative in medical school were significantly associated with poorer patient-centered behaviors, including lower attentiveness (b=-0.19, p = 0.01), friendliness (b=-0.28, p < 0.001), responsiveness (b=-0.21, p = 0.002), respectfulness (b=-0.17, p = 0.003), interactivity (b=-0.22, p = 0.003), likelihood of being recommended by observers (b=-0.34, p < 0.001), and patient-centeredness index scores (b=-0.16, p = 0.002). Student reported faculty role-modeling of discrimination against patients with obesity predicted lower friendliness (b=-0.16, p = 0.03), recommendation likelihood (b=-0.22, p = 0.04), and patient-centeredness index score (b=-0.12, p = 0.03).

CONCLUSIONS

Negative normative attitudes and behaviors regarding obesity in the medical school environment may adversely influence the quality of patient-centered behaviors provided to patients with obesity.

PRACTICE IMPLICATIONS

Efforts to improve patient-centered communication quality among medical trainees may benefit from intervention to improve group normative attitudes about patients with obesity.

A Longitudinal Study Exploring Learning Environment Culture and Subsequent Risk of Burnout Among Resident Physicians Overall and by Gender

OBJECTIVE

To explore the relationship between learning environment culture and the subsequent risk of developing burnout in a national sample of residents overall and by gender.

METHODS

From April 7 to August 2, 2016, and May 26 to August 5, 2017, we surveyed residents in their second (R2) and third (R3) postgraduate year. The survey included a negative interpersonal experiences scale (score range 1 to 7 points, higher being worse) assessing psychological safety and bias, inclusion, respect, and justice; an unfair treatment scale (score range 1 to 5 points, higher being worse), and two items from the Maslach Burnout Inventory. Individual responses to the R2 and R3 surveys were linked.

RESULTS

The R2 survey was completed by 3588 of 4696 (76.4%) residents; 3058 of 3726 (82.1%) residents completed the R3 survey; and 2888 residents completed both surveys. Women reported more negative interpersonal experiences (mean [SD], 3.00 [0.83] vs 2.90 [0.85], P<.001) and unfair treatment (66.5% vs. 58.7%, P<.001) than men at R2. On multivariable analysis, women at R3 were more likely than their male counterparts to have burnout (odds ratio, 1.23; 95% CI, 1.02 to 1.48; P=.03). Both men and women who reported more negative interpersonal experiences at R2 were more likely to have burnout at R3 (odds ratio, 1.32; 95% CI, 1.14 to 1.52; P<.001). The factors contributing to burnout did not vary in effect magnitude by gender.

CONCLUSION

These findings indicate women residents are more likely to have burnout relative to men in the third year of residency. Negative culture predicted subsequent burnout 1 year later among both men and women. Differences in burnout were at least partly due to differing levels of exposure to negative interactions for men versus women rather than a negative interaction having a differential impact on the well-being of men versus women.

Associations Between Experience of Early Childhood Trauma and Impact on Obesity Status, Health, as Well as Perceptions of Obesity-Related Health Care

OBJECTIVE

To evaluate the association between obesity and history of childhood trauma in an effort to define implications for the provider-patient relationship and possible causes of failure of obesity treatment.

METHODS

Multisite survey developed by the Patient-Centered Outcomes Research Institute Learning Health Systems Obesity Cohort Workgroup consisting of 49 questions with 2 questions focusing on history of being a victim of childhood physical and/or sexual abuse was mailed to 19,964 overweight or obese patients. Data collection for this survey occurred from October 27, 2017, through March 1, 2018.

RESULTS

Among the 2211 surveys included in analysis, respondents reporting being a victim of childhood abuse increased significantly with obesity (23.6%, 26.0%, 29.1%, and 36.8% for overweight, class I, class II, and class III obesity, respectively; P<.001). A higher percentage of those who reported being a victim of childhood abuse noted that their weight issues began at an earlier age (P=.002) and were more likely to have weight-related comorbidities (P<.001), even after controlling for body mass index. Impacting physician counseling on weight loss, patients who were childhood victims of abuse reported lower self-esteem (P<.001), were more likely to feel judged by their health care providers (P=.009), and less likely to feel being treated with respect (P=.045).

CONCLUSION

Overall, being a victim of childhood abuse was significantly associated with obesity, lower self-esteem and negative experiences interacting with health care providers. Health care providers should receive training to ensure open and nonjudgmental visits with obese patients and consider the role of trauma survivorship issues in patients' development of obesity and health care experiences.

Minority and low-income patients are less likely to have a scale for self-weighing in their home: A survey in primary care

Daily self-weighing is a weight management behaviour that requires a scale; however, scale ownership may be cost-prohibitive for some patients. Our objective was to understand the proportion of primary care patients with a scale at home, and factors associated with home scale access, to potentially inform future interventions that facilitate scale access. Cross sectional survey of 216 adult patients from three primary care clinics: mixed-income urban/suburban (n = 68); mixed-income urban (n = 70); low-income urban (n = 74). The dependent variable was presence of a home scale; bivariate associations were conducted with variables including demographics, insurance type, clinic setting and self-reported height/weight. Mean age was 53 years; 71% women; 71% racial minority; mean body mass index 32 kg/m2 . Overall, 56% had a home scale. Most (79%) white patients owned a scale, compared to 46% of racial minority patients (P < .01); 33% of low-income patients owned scale, compared to over 66% of patients at the clinics serving mixed-income populations (P < .01). Most low-income urban clinic patients do not own a home scale. Because self-weighing is an effective weight-management behaviour, clinicians could consider assessing scale access, and future research should assess the health impact of providing scales to patients with overweight/obesity who desire weight loss or maintenance.

The Value of Interracial Contact for Reducing Anti-Black Bias Among Non-Black Physicians: A Cognitive Habits and Growth Evaluation (CHANGE) Study Report

Although scholars have long studied circumstances that shape prejudice, inquiry into factors associated with long-term prejudice reduction has been more limited. Using a 6-year longitudinal study of non-Black physicians in training (N = 3,134), we examined the effect of three medical-school factors-interracial contact, medical-school environment, and diversity training-on explicit and implicit racial bias measured during medical residency. When accounting for all three factors, previous contact, and baseline bias, we found that quality of contact continued to predict lower explicit and implicit bias, although the effects were very small. Racial climate, modeling of bias, and hours of diversity training in medical school were not consistently related to less explicit or implicit bias during residency. These results highlight the benefits of interracial contact during an impactful experience such as medical school. Ultimately, professional institutions can play a role in reducing anti-Black bias by encouraging more frequent, and especially more favorable, interracial contact.

Contact and role modeling predict bias against lesbian and gay individuals among early-career physicians: A longitudinal study

RATIONALE

Physician bias against sexual minorities can hinder the delivery of high-quality health care and thus contribute to the disproportionate prevalence of negative health outcomes within this population. Medical students' interpersonal experiences within the context of medical school may contribute to this bias.

OBJECTIVE

The goal of the current research was to examine the relationship between these interpersonal experiences, reported by heterosexual, cisgender medical students, and explicit and implicit bias against lesbians and gay individuals, reported two years later during second year of medical residency.

METHOD

Data were collected by surveying students (n = 2940) from a stratified sample of U.S. medical schools in fall 2010 (first semester of medical school), spring 2014 (final semester of medical school), and spring 2016 (second year of medical residency).

RESULTS

Amount and favorability of contact with LGBT individuals, reported during the final semester of medical school, predicted lower levels of explicit bias against lesbian and gay individuals during second year of medical residency. Additionally, exposure to negative role modeling, also reported during the final semester of medical school, predicted higher levels of explicit bias against lesbian and gay individuals during second year of medical residency. Amount of contact with LGBT individuals - and in particular, with LGBT medical students - predicted lower levels of implicit bias against lesbian and gay individuals during second year of medical residency. Neither favorability of contact with LGBT individuals nor exposure to negative role modeling predicted implicit bias against lesbian and gay individuals during second year of medical residency.

CONCLUSION

These results suggest that interpersonal experiences during medical school can systematically shape heterosexual, cisgender physicians' subsequent explicit and implicit bias against lesbian and gay individuals.

The Effects of Racism in Medical Education on Students' Decisions to Practice in Underserved or Minority Communities

PURPOSE

The purpose of this study was to examine the relationship between manifestations of racism in medical school and subsequent changes in graduating medical students' intentions to practice in underserved or minority communities, compared with their attitudes and intentions at matriculation.

METHOD

The authors used repeated-measures data from a longitudinal study of 3,756 students at 49 U.S. medical schools that were collected from 2010 to 2014. They conducted generalized linear mixed models to estimate whether manifestations of racism in school curricula/policies, school culture/climate, or student attitudes/behaviors predicted first- to fourth-year changes in students' intentions to practice in underserved communities or primarily with minority populations. Analyses were stratified by students' practice intentions (no/undecided/yes) at matriculation.

RESULTS

Students' more negative explicit racial attitudes were associated with decreased intention to practice with underserved or minority populations at graduation. Service learning experiences and a curriculum focused on improving minority health were associated with increased intention to practice in underserved communities. A curriculum focused on minority health/disparities, students' perceived skill at developing relationships with minority patients, the proportion of minority students at the school, and the perception of a tense interracial environment were all associated with increased intention to care for minority patients.

CONCLUSIONS

This study provides evidence that racism manifested at multiple levels in medical schools was associated with graduating students' decisions to provide care in high-need communities. Strategies to identify and eliminate structural racism and its manifestations in medical school are needed.

Family caregiver satisfaction with inpatient rehabilitation care

INTRODUCTION

Informal family caregivers play an increasingly important role in healthcare. Despite their role in ongoing management and coordination of care, caregiver satisfaction with the healthcare services care recipients receive has been understudied. We sought to assess what influences caregiver satisfaction with inpatient care provided to their care recipient among caregivers of veterans with traumatic brain injury (TBI) and polytrauma.

METHODS

Data from the Family and Caregiver Experience Survey, a national survey of caregivers of veterans with TBI and polytrauma, was used to explore factors associated with caregiver satisfaction with the care his/her care recipient received while an inpatient at a US Department of Veterans Affairs (VA) Polytrauma Rehabilitation Center. Caregiver and care recipient demographic and injury factors and potential addressable factors including social support, caregiver training received, and caregiver perceptions of being valued by the VA were evaluated for their associations with caregivers' satisfaction with their care recipients' healthcare.

RESULTS

The majority of the 524 caregivers reported being mostly or very satisfied with their care recipient's inpatient care (75%, n = 393). Higher satisfaction with inpatient care was significantly associated with greater caregiver social support, receipt of training from the VA, and perceptions of being valued by the VA, both on univariate analysis and after controlling for care recipient TBI severity and caregiver's relationship to the care recipient.

CONCLUSIONS

Results suggest that supporting a strong social network for caregivers, providing caregiver training, and employing practices that communicate that family caregiving is valued by providers and healthcare organizations are promising avenues for improving caregiver satisfaction.

A Prognostic Index to Identify the Risk of Developing Depression Symptoms Among U.S. Medical Students Derived From a National, Four-Year Longitudinal Study

PURPOSE

To determine baseline individual and school-related factors associated with increased risk of developing depression symptoms by year four (Y4) of medical school, and to develop a prognostic index that stratifies risk of developing depression symptoms (Depression-PI) among medical students.

METHOD

The authors analyzed data from 3,743 students (79% of 4,732) attending 49 U.S. medical schools who completed baseline (2010) and Y4 (2014) surveys. Surveys included validated scales measuring depression, stress, coping, and social support. The authors collected demographics and school characteristics and conducted multivariate analysis to identify baseline factors independently associated with Y4 depression symptoms. They used these factors to create a prognostic index for developing depression. They randomly divided the data into discovery (n = 2,455) and replication (n = 1,288) datasets and calculated c statistics (c).

RESULTS

The authors identified eight independent prognostic factors for experiencing depression symptoms during training within the discovery dataset: age; race; ethnicity; tuition; and baseline depression symptoms, stress, coping behaviors, and social support. The Depression-PI stratified four risk groups. Compared with the low risk group, those in the intermediate, high, and very high risk groups had an odds ratio of developing depression of, respectively, 1.75, 3.98, and 9.19 (c = 0.71). The replication dataset confirmed the risk groups.

CONCLUSIONS

Demographics; tuition; and baseline depression symptoms, stress, coping behaviors, and social support are independently associated with risk of developing depression during training among U.S. medical students. By stratifying students into four risk groups, the Depression-PI may allow for a tiered primary prevention approach.

Factors influencing medical student self-competence to provide weight management services

This study aimed to identify factors associated with high obesity care self-competence among US medical students. The authors performed a cross-sectional analysis of 2014 survey data on fourth year medical students collected online as part of the Medical Student Cognitive Habits and Growth Evaluation Study (CHANGES). Independent variables included quality and quantity of interaction with patients and peers with obesity; hours of communication and partnership skills training; negative remarks against patients with obesity by supervising physicians, and witnessed discrimination against patients with obesity. The dependent variable was self-competence in providing obesity care. Of 5823 students invited to participate, 3689 (63%) responded and were included in our analyses. Most students were white (65%), half were women and 42% had high self-competence in caring for patients with obesity. Factors associated with high self-competence included increased interaction with peers with obesity (39% vs. 49%, P < 0.001) and increased partnership skills training (32% vs. 61%, P < 0.001). Increased partnership skills training and quantity of interactions with peers with obesity were associated with high student self-competence in providing obesity-related care to patients. Medical schools might consider increasing partnership skills training to improve students' preparedness and skill in performing obesity-related care.

An update on research examining the implications of stigma for access to and utilization of bariatric surgery

PURPOSE OF REVIEW

To summarize recent literature examining the relationship between stigma and utilization of surgical treatments for obesity.

RECENT FINDINGS

The stigma of obesity and stigma associated with surgical treatments for obesity can affect both healthcare providers' recommendations of these options and patients' likelihood of considering and choosing these treatments. Presurgical requirements of healthcare and insurance organizations and a lack of postsurgical support reflect the stigmatizing attitudes that bariatric/metabolic surgery is an 'easy fix' and 'last resort' for patients too undisciplined to lose weight in other ways.

SUMMARY

Here we review the literature published in the last year that addresses the implications of stigma for the utilization and outcomes of surgical treatments for obesity.

Needs Assessment for Weight Management: The Learning Health System Network Experience

Objective

To assess patients' weight management needs and experiences across multiple sites within the Learning Health System Network.

Patients and Methods

A total of 19,964 surveys were sent to patients identified with overweight or obesity through medical record query at 5 health care systems throughout 11 states. The survey collected patients' experiences with and opinions about weight management in clinical care from October 27, 2017, through March 1, 2018.

Results

Among the 2380 responders, being younger, female, nonwhite, and single and having some college education or less were all significantly associated with higher body mass index (BMI). The most frequent weight loss barriers included food cravings (30.7%-49.9%) and having a medical condition limiting physical activity (17.7%-47.1%) (P<.001). Higher BMI was associated with a higher frequency of comorbidities and lower health status (P<.001). Higher BMI was also associated with a higher belief that primary care providers (PCPs) should be involved in weight loss management (P=.01) but lower belief that the PCP had the necessary skills and knowledge to help (P<.001). Responders with a higher BMI were more likely to feel judged (P<.001) and not always respected (P<.001) by their PCP. In addition, those with a higher BMI more frequently reported avoiding health care visits because of weight gain, not wanting to undress or be weighed, and not wanting to discuss their weight with their PCP (P<.001).

Conclusion

Physician involvement in weight management is important to patients whose needs and experiences differ by BMI. These data may inform clinical weight management efforts and create greater alignment with patient expectations.

Association of Clinical Specialty With Symptoms of Burnout and Career Choice Regret Among US Resident Physicians

IMPORTANCE

Burnout among physicians is common and has been associated with medical errors and lapses in professionalism. It is unknown whether rates for symptoms of burnout among resident physicians vary by clinical specialty and if individual factors measured during medical school relate to the risk of burnout and career choice regret during residency.

OBJECTIVE

To explore factors associated with symptoms of burnout and career choice regret during residency.

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort study of 4732 US resident physicians. First-year medical students were enrolled between October 2010 and January 2011 and completed the baseline questionnaire. Participants were invited to respond to 2 questionnaires; one during year 4 of medical school (January-March 2014) and the other during the second year of residency (spring of 2016). The last follow-up was on July 31, 2016.

EXPOSURES

Clinical specialty, demographic characteristics, educational debt, US Medical Licensing Examination Step 1 score, and reported levels of anxiety, empathy, and social support during medical school.

MAIN OUTCOMES AND MEASURES

Prevalence during second year of residency of reported symptoms of burnout measured by 2 single-item measures (adapted from the Maslach Burnout Inventory) and an additional item that evaluated career choice regret (defined as whether, if able to revisit career choice, the resident would choose to become a physician again).

RESULTS

Among 4696 resident physicians, 3588 (76.4%) completed the questionnaire during the second year of residency (median age, 29 [interquartile range, 28.0-31.0] years in 2016; 1822 [50.9%] were women). Symptoms of burnout were reported by 1615 of 3574 resident physicians (45.2%; 95% CI, 43.6% to 46.8%). Career choice regret was reported by 502 of 3571 resident physicians (14.1%; 95% CI, 12.9% to 15.2%). In a multivariable analysis, training in urology, neurology, emergency medicine, and general surgery were associated with higher relative risks (RRs) of reported symptoms of burnout (range of RRs, 1.24 to 1.48) relative to training in internal medicine. Characteristics associated with higher risk of reported symptoms of burnout included female sex (RR, 1.17 [95% CI, 1.07 to 1.28]; risk difference [RD], 7.2% [95% CI, 3.1% to 11.3%]) and higher reported levels of anxiety during medical school (RR, 1.08 per 1-point increase [95% CI, 1.06 to 1.11]; RD, 1.8% per 1-point increase [95% CI, 1.6% to 2.0%]). A higher reported level of empathy during medical school was associated with a lower risk of reported symptoms of burnout during residency (RR, 0.99 per 1-point increase [95% CI, 0.99 to 0.99]; RD, -0.5% per 1-point increase [95% CI, -0.6% to -0.3%]). Reported symptoms of burnout (RR, 3.20 [95% CI, 2.58 to 3.82]; RD, 15.0% [95% CI, 12.8% to 17.3%]) and clinical specialty (range of RRs, 1.66 to 2.60) were both significantly associated with career choice regret.

CONCLUSIONS AND RELEVANCE

Among US resident physicians, symptoms of burnout and career choice regret were prevalent, but varied substantially by clinical specialty. Further research is needed to better understand these differences and to address these issues.

The Impact of Stigma on Community Reintegration of Veterans With Traumatic Brain Injury and the Well-Being of Their Caregivers

OBJECTIVE

To assess the association between perceived stigma and discrimination and caregiver strain, caregiver well-being, and patient community reintegration.

DESIGN

A cross-sectional survey study of 564 informal caregivers of U.S. military service veterans of wars in Iraq and Afghanistan who experienced traumatic brain injuries or polytrauma (TBI/PT).

SETTING

Care settings of community-dwelling former inpatients of U.S. Department of Veterans Affairs Polytrauma Rehabilitation Centers.

PARTICIPANTS

Caregivers of former inpatients (N=564), identified through next-of-kin records and subsequent nominations.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Caregiver strain, depression, anxiety, loneliness, and self-esteem; as well as care recipient community reintegration, a key aspect of TBI/PT rehabilitation.

RESULTS

Family stigma was associated with strain, depression, anxiety, loneliness, lower self-esteem, and less community reintegration. Caregiver stigma-by-association was associated with strain, depression, anxiety, loneliness, and lower self-esteem. Care recipient stigma was associated with caregiver strain, depression, anxiety, loneliness, lower self-esteem, and less community reintegration.

CONCLUSIONS

Perceived stigma may be a substantial source of stress for caregivers of U.S. military veterans with TBI/PT, and may contribute to poor outcomes for the health of caregivers and for the community reintegration of the veterans for whom they provide care.

Medical School Factors Associated with Changes in Implicit and Explicit Bias Against Gay and Lesbian People among 3492 Graduating Medical Students

BACKGROUND

Implicit and explicit bias among providers can influence the quality of healthcare. Efforts to address sexual orientation bias in new physicians are hampered by a lack of knowledge of school factors that influence bias among students.

OBJECTIVE

To determine whether medical school curriculum, role modeling, diversity climate, and contact with sexual minorities predict bias among graduating students against gay and lesbian people.

DESIGN

Prospective cohort study.

PARTICIPANTS

A sample of 4732 first-year medical students was recruited from a stratified random sample of 49 US medical schools in the fall of 2010 (81% response; 55% of eligible), of which 94.5% (4473) identified as heterosexual. Seventy-eight percent of baseline respondents (3492) completed a follow-up survey in their final semester (spring 2014).

MAIN MEASURES

Medical school predictors included formal curriculum, role modeling, diversity climate, and contact with sexual minorities. Outcomes were year 4 implicit and explicit bias against gay men and lesbian women, adjusted for bias at year 1.

KEY RESULTS

In multivariate models, lower explicit bias against gay men and lesbian women was associated with more favorable contact with LGBT faculty, residents, students, and patients, and perceived skill and preparedness for providing care to LGBT patients. Greater explicit bias against lesbian women was associated with discrimination reported by sexual minority students (b = 1.43 [0.16, 2.71]; p = 0.03). Lower implicit sexual orientation bias was associated with more frequent contact with LGBT faculty, residents, students, and patients (b = -0.04 [-0.07, -0.01); p = 0.008). Greater implicit bias was associated with more faculty role modeling of discriminatory behavior (b = 0.34 [0.11, 0.57); p = 0.004).

CONCLUSIONS

Medical schools may reduce bias against sexual minority patients by reducing negative role modeling, improving the diversity climate, and improving student preparedness to care for this population.

Beyond Generalized Sexual Prejudice: Need for Closure Predicts Negative Attitudes Toward Bisexual People Relative to Gay/Lesbian People

Increasing evidence suggests that bisexual people are sometimes evaluated more negatively than heterosexual and gay/lesbian people. A common theoretical account for this discrepancy argues that bisexuality is perceived by some as introducing ambiguity into a binary model of sexuality. The present brief report tests a single key prediction of this theory, that evaluations of bisexual people have a unique relationship with Need for Closure (NFC), a dispositional preference for simple ways of structuring information. Participants (n=3406) were heterosexual medical students from a stratified random sample of 49 U.S. medical schools. As in prior research, bisexual targets were evaluated slightly more negatively than gay/lesbian targets overall. More importantly for the present investigation, higher levels of NFC predicted negative evaluations of bisexual people after accounting for negative evaluations of gay/lesbian people, and higher levels of NFC also predicted an explicit evaluative preference for gay/lesbian people over bisexual people. These results suggest that differences in evaluations of sexual minority groups partially reflect different psychological processes, and that NFC may have a special relevance for bisexual targets even beyond its general association with prejudice. The practical value of testing this theory on new physicians is also discussed.

Burden and mental health among caregivers of veterans with traumatic brain injury/polytrauma

Veterans who survive multiple traumatic injuries, including traumatic brain injuries (TBI), must often rely on family caregivers for ongoing care and support with reintegration. Understanding factors associated with caregiving that help or harm caregivers' health is critical for identifying appropriate and effective interventions that support caregiver health and promote the provision of quality care to veterans. This study utilized cross-sectional data from the Family and Caregiver Experiences Study, a survey of 564 caregivers caring for veterans who served after September 11, 2001, survived TBI/polytrauma during service, and received inpatient rehabilitation care in a Veterans Affairs Polytrauma Rehabilitation Center. Structural equation modeling was used to examine the relationship between caregiver stress (i.e., veterans' neurobehavioral problems and intensity of care required), and caregiver well-being (i.e., caregiver burden and mental health). Analyses also examined how intrapersonal, family or social, and financial resources mediate and moderate the relationship between caregiver stress and well-being. Results indicate that veterans' neurobehavioral problems and intensity of required care were associated with more caregiver burden, and more burden was associated with poor mental health. Intrapersonal and family or social resources mediated the relationship between veteran functioning and mental health. Family or social resources also moderated the relationship between care intensity and burden. The model explained a moderate amount of variability in burden (59%) and a substantial amount in mental health (75%). We conclude that caregivers of veterans with neurobehavioral problems who require intense care are at risk for burden and poor mental health. Increasing resources to bolster family or social resources may reduce risks. (PsycINFO Database Record

Social Dominance Orientation, Dispositional Empathy, and Need for Cognitive Closure Moderate the Impact of Empathy-Skills Training, but Not Patient Contact, on Medical Students' Negative Attitudes toward Higher-Weight Patients

Anti-fat bias in healthcare providers and medical students has serious implications for quality of care of higher-weight patients. Studies of interventions aimed at reducing anti-fat attitudes in medical students have generally been disappointing, with little enduring effect. It is possible that some students may be more receptive to prejudice-reducing influences than others, due to underlying differences in their personal characteristics. It is also possible that attitudes toward patients, specifically, may differ from anti-fat attitudes in general, and prejudice-reduction effectiveness on patient-specific attitudes has not yet been evaluated. The present study explored the effect on general and patient-specific anti-fat attitudes of (1) contact with higher-weight individuals prior to and during medical school; and (2) training designed to increase medical students' empathy toward patients by encouraging them to take the patient's perspective during clinical encounters. The moderating role of individual difference factors on effectiveness of contact and student-reported hours of empathy training on patient-specific attitudes was assessed. A total of 3,576 students enrolled across 49 US medical schools completed an online survey at the start of their first year of medical school and at the end of their fourth year. Favorable contact experience with higher-weight patients predicted improved attitudes toward heavier patients after 4 years of medical school, and appeared sufficient to partially offset the effects of dislike of higher-weight individuals at baseline. The impact of favorable contact on general anti-fat attitudes was less strong, highlighting the importance of using target-specific outcome measures. The positive effects of favorable contact on attitudes toward higher-weight patients did not differ based on students' baseline levels of social dominance orientation, dispositional empathy, or need for cognitive closure. In contrast, the effectiveness of training did vary by student characteristics, generally being more effective in students who were more egalitarian and empathic at baseline, with little effect, or even adverse effects in students low in these traits. Overall, however, perspective-taking training produced only small improvements in attitudes toward higher-weight patients.

Informal Training Experiences and Explicit Bias Against African Americans among Medical Students

Despite the widespread inclusion of diversity-related curricula in US medical training, racial disparities in the quality of care and physician bias in medical treatment persist. The present study examined the effects of both formal and informal experiences on non-African American medical students' (N=2922) attitudes toward African Americans in a longitudinal study of 49 randomly selected US medical schools. We assessed the effects experiences related to medical training, accounting for prior experiences and attitudes. Contact with African Americans predicted positive attitudes toward African Americans relative to White people, even beyond the effects of prior attitudes. Furthermore, students who reported witnessing instructors making negative racial comments or jokes were significantly more willing to express racial bias themselves, even after accounting for the effects of contact. Examining the effects of informal experiences on racial attitudes may help develop a more effective medical training environment and reduce racial disparities in healthcare.

Mental Well-Being in First Year Medical Students: A Comparison by Race and Gender: A Report from the Medical Student CHANGE Study

PURPOSE

In this study, authors sought to characterize race and gender disparities in mental health in a national sample of first year medical students early in their medical school experience.

METHOD

This study used cross-sectional baseline data of Medical Student CHANGES, a large national longitudinal study of a cohort of medical students surveyed in the winter of 2010. Authors ascertained respondents via the American Association of Medical Colleges questionnaire, a third-party vendor-compiled list, and referral sampling.

RESULTS

A total of 4732 first year medical students completed the baseline survey; of these, 301 were African American and 2890 were White. Compared to White students and after adjusting for relevant covariates, African American students had a greater risk of being classified as having depressive (relative risk (RR)=1.59 [95 % confidence interval, 1.37-2.40]) and anxiety symptoms (RR=1.66 [1.08-2.71]). Women also had a greater risk of being classified as having depressive (RR=1.36 [1.07-1.63]) and anxiety symptoms (RR-1.95 [1.39-2.84]).

CONCLUSIONS

At the start of their first year of medical school, African American and female medical students were at a higher risk for depressive symptoms and anxiety than their White and male counterparts, respectively. The findings of this study have practical implications as poor mental and overall health inhibit learning and success in medical school, and physician distress negatively affects quality of clinical care.

Medical students' learning orientation regarding interracial interactions affects preparedness to care for minority patients: a report from Medical Student CHANGES

BACKGROUND

There is a paucity of evidence on how to train medical students to provide equitable, high quality care to racial and ethnic minority patients. We test the hypothesis that medical schools' ability to foster a learning orientation toward interracial interactions (i.e., that students can improve their ability to successfully interact with people of another race and learn from their mistakes), will contribute to white medical students' readiness to care for racial minority patients. We then test the hypothesis that white medical students who perceive their medical school environment as supporting a learning orientation will benefit more from disparities training.

METHODS

Prospective observational study involving web-based questionnaires administered during first (2010) and last (2014) semesters of medical school to 2394 white medical students from a stratified, random sample of 49 U.S. medical schools. Analysis used data from students' last semester to build mixed effects hierarchical models in order to assess the effects of medical school interracial learning orientation, calculated at both the school and individual (student) level, on key dependent measures.

RESULTS

School differences in learning orientation explained part of the school difference in readiness to care for minority patients. However, individual differences in learning orientation accounted for individual differences in readiness, even after controlling for school-level learning orientation. Individual differences in learning orientation significantly moderated the effect of disparities training on white students' readiness to care for minority patients. Specifically, white medical students who perceived a high level of learning orientation in their medical schools regarding interracial interactions benefited more from training to address disparities.

CONCLUSIONS

Coursework aimed at reducing healthcare disparities and improving the care of racial minority patients was only effective when white medical students perceived their school as having a learning orientation toward interracial interactions. Results suggest that medical school faculty should present interracial encounters as opportunities to practice skills shown to reduce bias, and faculty and students should be encouraged to learn from one another about mistakes in interracial encounters. Future research should explore aspects of the medical school environment that contribute to an interracial learning orientation.

Medical School Experiences Associated with Change in Implicit Racial Bias Among 3547 Students: A Medical Student CHANGES Study Report

BACKGROUND

Physician implicit (unconscious, automatic) bias has been shown to contribute to racial disparities in medical care. The impact of medical education on implicit racial bias is unknown.

OBJECTIVE

To examine the association between change in student implicit racial bias towards African Americans and student reports on their experiences with 1) formal curricula related to disparities in health and health care, cultural competence, and/or minority health; 2) informal curricula including racial climate and role model behavior; and 3) the amount and favorability of interracial contact during school.

DESIGN

Prospective observational study involving Web-based questionnaires administered during first (2010) and last (2014) semesters of medical school.

PARTICIPANTS

A total of 3547 students from a stratified random sample of 49 U.S. medical schools.

MAIN OUTCOME(S) AND MEASURE(S)

Change in implicit racial attitudes as assessed by the Black-White Implicit Association Test administered during the first semester and again during the last semester of medical school.

KEY RESULTS

In multivariable modeling, having completed the Black-White Implicit Association Test during medical school remained a statistically significant predictor of decreased implicit racial bias (-5.34, p ≤ 0.001: mixed effects regression with random intercept across schools). Students' self-assessed skills regarding providing care to African American patients had a borderline association with decreased implicit racial bias (-2.18, p = 0.056). Having heard negative comments from attending physicians or residents about African American patients (3.17, p = 0.026) and having had unfavorable vs. very favorable contact with African American physicians (18.79, p = 0.003) were statistically significant predictors of increased implicit racial bias.

CONCLUSIONS

Medical school experiences in all three domains were independently associated with change in student implicit racial attitudes. These findings are notable given that even small differences in implicit racial attitudes have been shown to affect behavior and that implicit attitudes are developed over a long period of repeated exposure and are difficult to change.

Beliefs about the causes of obesity in a national sample of 4th year medical students

OBJECTIVE

Physician knowledge of the complex contributors to obesity varies. We do not know whether today's medical students are graduating with deep understanding of the causes of obesity. Our objective was to assess beliefs about causes of obesity in a national sample of 4th year medical students.

METHOD

We randomly selected 2000 4th year students from a random sample of 50 U.S. medical schools and asked them to rate the importance of several factors as causes of obesity. Of those invited, 1244 (62%) responded. We conducted latent class analysis to identify groups with similar response patterns.

RESULTS

Most students demonstrated knowledge that obesity has multiple contributors. Students fell into 1 of 4 classes: (1) more likely to endorse all contributors (28%), (2) more likely to endorse physiological contributors (27%), (3) more likely to endorse behavioral or social contributors (24%), and (4) unlikely to endorse contributors outside of overeating and physical activity (22%).

CONCLUSION

Though students were generally aware of multiple causes, there were 4 distinct patterns of beliefs, with implications for patient care.

PRACTICE IMPLICATIONS

Targeted interventions may help to improve depth of knowledge about the causes of obesity and lead to more effective care for obese patients.

The mixed impact of medical school on medical students' implicit and explicit weight bias

CONTEXT

Health care trainees demonstrate implicit (automatic, unconscious) and explicit (conscious) bias against people from stigmatised and marginalised social groups, which can negatively influence communication and decision making. Medical schools are well positioned to intervene and reduce bias in new physicians.

OBJECTIVES

This study was designed to assess medical school factors that influence change in implicit and explicit bias against individuals from one stigmatised group: people with obesity.

METHODS

This was a prospective cohort study of medical students enrolled at 49 US medical schools randomly selected from all US medical schools within the strata of public and private schools and region. Participants were 1795 medical students surveyed at the beginning of their first year and end of their fourth year. Web-based surveys included measures of weight bias, and medical school experiences and climate. Bias change was compared with changes in bias in the general public over the same period. Linear mixed models were used to assess the impact of curriculum, contact with people with obesity, and faculty role modelling on weight bias change.

RESULTS

Increased implicit and explicit biases were associated with less positive contact with patients with obesity and more exposure to faculty role modelling of discriminatory behaviour or negative comments about patients with obesity. Increased implicit bias was associated with training in how to deal with difficult patients. On average, implicit weight bias decreased and explicit bias increased during medical school, over a period of time in which implicit weight bias in the general public increased and explicit bias remained stable.

CONCLUSIONS

Medical schools may reduce students' weight biases by increasing positive contact between students and patients with obesity, eliminating unprofessional role modelling by faculty members and residents, and altering curricula focused on treating difficult patients.

The Adverse Effect of Weight Stigma on the Well-Being of Medical Students with Overweight or Obesity: Findings from a National Survey

BACKGROUND

The stigma of obesity is a common and overt social bias. Negative attitudes and derogatory humor about overweight/obese individuals are commonplace among health care providers and medical students. As such, medical school may be particularly threatening for students who are overweight or obese.

OBJECTIVE

The purpose of our study was to assess the frequency that obese/overweight students report being stigmatized, the degree to which stigma is internalized, and the impact of these factors on their well-being.

DESIGN

We performed cross-sectional analysis of data from the Medical Student Cognitive Habits and Growth Evaluation Study (CHANGES) survey.

PARTICIPANTS

A total of 4,687 first-year medical students (1,146 overweight/obese) from a stratified random sample of 49 medical schools participated in the study.

MAIN MEASURES

Implicit and explicit self-stigma were measured with the Implicit Association Test and Anti-Fat Attitudes Questionnaire. Overall health, anxiety, depression, fatigue, self-esteem, sense of mastery, social support, loneliness, and use of alcohol/drugs to cope with stress were measured using previously validated scales.

KEY RESULTS

Among obese and overweight students, perceived stigma was associated with each measured component of well-being, including anxiety (beta coefficient [b] = 0.18; standard error [SE] = 0.03; p < 0.001) and depression (b = 0.20; SE = 0.03; p < 0.001). Among the subscales of the explicit self-stigma measure, dislike of obese people was associated with several factors, including depression (b = 0.07; SE =  .01; p < 0.001), a lower sense of mastery (b = -0.10; SE = 0.02; p < 0.001), and greater likelihood of using drugs or alcohol to cope with stress (b =  .05; SE = 0.01; p < 0.001). Fear of becoming fat was associated with each measured component of well-being, including lower body esteem (b = -0.25; SE = 0.01; p < 0.001) and less social support (b = -0.06; SE = 0.01; p < 0.001). Implicit self-stigma was not consistently associated with well-being factors. Compared to normal-weight/underweight peers, overweight/obese medical students had worse overall health (b = -0.33; SE = 0.03; p < 0.001) and body esteem (b = -0.70; SE = 0.02; p < 0.001), and overweight/obese female students reported less social support (b = -0.12; SE = 0.03; p < 0.001) and more loneliness (b = 0.22; SE = 0.04; p < 0.001).

CONCLUSIONS

Perceived and internalized weight stigma may contribute to worse well-being among overweight/obese medical students.

Prevalence and etiologies of adult communication disabilities in the United States: Results from the 2012 National Health Interview Survey

BACKGROUND

Communication disabilities, including speech, language and voice disabilities, can significantly impact a person's quality of life, employment and health status. Despite this, little is known about the prevalence and etiology of communication disabilities in the general adult population.

OBJECTIVES

To assess the prevalence and etiology of communication disabilities in a nationally representative adult sample.

METHODS

We conducted a cross-sectional study and analyzed the responses of non-institutionalized adults to the Sample Adult Core questionnaire within the 2012 National Health Interview Survey. We used respondents' self-report of having a speech, language or voice disability within the past year and receiving a diagnosis for one of these communication disabilities, as well as the etiology of their communication disability. We additionally examined the responses by subgroups, including sex, age, race and ethnicity, and geographical area.

RESULTS

In 2012 approximately 10% of the US adult population reported a communication disability, while only 2% of adults reported receiving a diagnosis. The rates of speech, language and voice disabilities and diagnoses varied across gender, race/ethnicity and geographic groups. The most common response for the etiology of a communication disability was "something else."

CONCLUSIONS

Improved understanding of population prevalence and etiologies of communication disabilities will assist in appropriately directing rehabilitation and medical services; potentially reducing the burden of communication disabilities.

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

PURPOSE

A recent Institute of Medicine report concluded that lesbian and gay individuals face discrimination from health care providers and called for research on provider attitudes. Medical school is a critical juncture for improving future providers' treatment of sexual minorities. This study examined both explicit bias and implicit bias against lesbian women and gay men among first-year medical students, focusing on two predictors of such bias, contact and empathy.

METHOD

This study included the 4,441 heterosexual first-year medical students who participated in the baseline survey of the Medical Student Cognitive Habits and Growth Evaluation Study, which employed a stratified random sample of 49 U.S. medical schools in fall 2010. The researchers measured explicit attitudes toward gay and lesbian people using feeling thermometer self-assessments, implicit attitudes using the Implicit Association Test, amount and favorability of contact using self-report items, and empathy using subscales of the Interpersonal Reactivity Index.

RESULTS

Nearly half (45.79%; 956/2,088) of respondents with complete data on both bias measures expressed at least some explicit bias, and most (81.51%; 1,702/2,088) exhibited at least some implicit bias against gay and lesbian individuals. Both amount and favorability of contact predicted positive implicit and explicit attitudes. Both cognitive and emotional empathy predicted positive explicit attitudes, but not implicit attitudes.

CONCLUSIONS

The prevalence of negative attitudes presents an important challenge for medical education, highlighting the need for more research on possible causes of bias. Findings on contact and empathy point to possible curriculum-based interventions aimed at ensuring high-quality care for sexual minorities.

A Comparison of the Mental Health and Well-Being of Sexual Minority and Heterosexual First-Year Medical Students: A Report From the Medical Student CHANGE Study

PURPOSE

Research is lacking on psychological distress and disorder among sexual minority medical students (students who identify as nonheterosexual). If left unaddressed, distress may result in academic and professional difficulties and undermine workforce diversity goals. The authors compared depression, anxiety, and self-rated health among sexual minority and heterosexual medical students.

METHOD

This study included 4,673 first-year students who self-reported sexual orientation in the fall 2010 baseline survey of the Medical Student Cognitive Habits and Growth Evaluation Study, a national longitudinal cohort study. The authors used items from published scales to measure depression, anxiety, self-rated health, and social stressors. They conducted bivariate and multivariate analyses to estimate the association between sexual identity and depression, anxiety, and self-rated health.

RESULTS

Of 4,673 students, 232 (5.0%) identified as a sexual minority. Compared with heterosexual students, after adjusting for relevant covariates, sexual minority students had greater risk of depressive symptoms (adjusted relative risk [ARR] = 1.59 [95% confidence interval, 1.24-2.04]), anxiety symptoms (ARR = 1.64 [1.08-2.49]), and low self-rated health (ARR = 1.77 [1.15-2.60]). Sexual minority students were more likely to report social stressors, including harassment (22.7% versus 12.7%, P < .001) and isolation (53.7% versus 42.8%, P = .001). Exposure to social stressors attenuated but did not eliminate the observed associations between minority sexual identity and mental and self-reported health measures.

CONCLUSIONS

First-year sexual minority students experience significantly greater risk of depression, anxiety, and low self-rated health than heterosexual students. Targeted interventions are needed to improve mental health and well-being.

Impact of weight bias and stigma on quality of care and outcomes for patients with obesity

The objective of this study was to critically review the empirical evidence from all relevant disciplines regarding obesity stigma in order to (i) determine the implications of obesity stigma for healthcare providers and their patients with obesity and (ii) identify strategies to improve care for patients with obesity. We conducted a search of Medline and PsychInfo for all peer-reviewed papers presenting original empirical data relevant to stigma, bias, discrimination, prejudice and medical care. We then performed a narrative review of the existing empirical evidence regarding the impact of obesity stigma and weight bias for healthcare quality and outcomes. Many healthcare providers hold strong negative attitudes and stereotypes about people with obesity. There is considerable evidence that such attitudes influence person-perceptions, judgment, interpersonal behaviour and decision-making. These attitudes may impact the care they provide. Experiences of or expectations for poor treatment may cause stress and avoidance of care, mistrust of doctors and poor adherence among patients with obesity. Stigma can reduce the quality of care for patients with obesity despite the best intentions of healthcare providers to provide high-quality care. There are several potential intervention strategies that may reduce the impact of obesity stigma on quality of care.

Patient characteristics associated with the level of patient-reported care coordination among male patients with colorectal cancer in the Veterans Affairs health care system

BACKGROUND

The current study was performed to determine whether patient characteristics, including race/ethnicity, were associated with patient-reported care coordination for patients with colorectal cancer (CRC) who were treated in the Veterans Affairs (VA) health care system, with the goal of better understanding potential goals of quality improvement efforts aimed at improving coordination.

METHODS

The nationwide Cancer Care Assessment and Responsive Evaluation Studies survey involved VA patients with CRC who were diagnosed in 2008 (response rate, 67%). The survey included a 4-item scale of patient-reported frequency ("never," "sometimes," "usually," and "always") of care coordination activities (scale score range, 1-4). Among 913 patients with CRC who provided information regarding care coordination, demographics, and symptoms, multivariable logistic regression was used to examine odds of patients reporting optimal care coordination.

RESULTS

VA patients with CRC were found to report high levels of care coordination (mean scale score, 3.50 [standard deviation, 0.61]). Approximately 85% of patients reported a high level of coordination, including the 43% reporting optimal/highest-level coordination. There was no difference observed in the odds of reporting optimal coordination by race/ethnicity. Patients with early-stage disease (odds ratio [OR], 0.60; 95% confidence interval [95% CI], 0.45-0.81), greater pain (OR, 0.97 for a 1-point increase in pain scale; 95% CI, 0.96-0.99), and greater levels of depression (OR, 0.97 for a 1-point increase in depression scale; 95% CI, 0.96-0.99) were less likely to report optimal coordination.

CONCLUSIONS

Patients with CRC in the VA reported high levels of care coordination. Unlike what has been reported in settings outside the VA, there appears to be no racial/ethnic disparity in reported coordination. However, challenges remain in ensuring coordination of care for patients with less advanced disease and a high symptom burden. Cancer 2015;121:2207-2213. © 2015 American Cancer Society.