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Avant ND, Weed E, Connelly C, Hincapie AL, Penm J. Qualitative Analysis of Student Pharmacists' Reflections of Harvard's Race Implicit Association Test. CURRENTS IN PHARMACY TEACHING & LEARNING 2018; 10:611-617. [PMID: 29986821 DOI: 10.1016/j.cptl.2018.02.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 11/17/2017] [Accepted: 02/01/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND AND PURPOSE Identify and analyze pharmacy students' perceptions about their own implicit racial biases. EDUCATIONAL ACTIVITY AND SETTING First year pharmacy students (n = 97) enrolled in a Pharmacy Practice course completed a test, Harvard Race Implicit Association Test (IAT), for homework to uncover their unconscious black-white racial bias. All students then wrote at least one paragraph reflecting on if they agreed or disagreed with their results and why. At the beginning of class, students were given a brief survey to capture their IAT results and demographic information. Retrospectively and following Institutional Review Board approval, pharmacy students' reflections were subjected to thematic analysis with the assistance of NVivo 10 and descriptive analyses were completed of their demographic info. FINDINGS Out of the 97 students enrolled in this course, all completed the self-reflection. But only 90 completed the survey. From those that completed the survey, 54% (N = 49) self-identified as women. The average age was 22.6 years old. Most of the students (77%) identified themselves as White Non-Hispanic. Six percent (N = 5) identified as Black. Most students (66%) reported that their results from the Race IAT indicated some level of preference for European Americans; 13% of the students reported some level of preference for African-Americans. All students' reflections were categorized by their agreement or lack of agreement with their implicit association test results. Those that agreed with their results cited family, friends, and community contributing to their implicit biases. Students who did not agree with their results were subcategorized as denying their results, believing that their implicit association did not affect their behavior, or believing that the Race IAT was invalid. DISCUSSION/SUMMARY Many pharmacy students were found to be unaware of their implicit biases and some do not believe that these biases will negatively affect the treatment of others. Pharmacy curricula should be developed to provide adequate self-awareness training and space in the curriculum so students can challenge these unconscious beliefs.
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Affiliation(s)
- Nicole D Avant
- University of Cincinnati Division of Experience-Based Learning and Career Education, Assistant Professor, 735K Joseph A. Steger Student Life Center, Cincinnati, Ohio 45221, United States.
| | - Elizabeth Weed
- University of Cincinnati College of Pharmacy, Assistant Professor of Pharmacy Practice, 3225 Eden Ave., Cincinnati, Ohio 45267, United States.
| | - Chloe Connelly
- University of Cincinnati, Master's in Sociology, 5386 Hanley Road, Cincinnati, OH, 45247, United States.
| | - Ana L Hincapie
- University of Cincinnati College of Pharmacy, Assistant Professor of Pharmacy Practice, 3225 Eden Ave., Cincinnati, Ohio 45267, United States.
| | - Jonathan Penm
- Faculty of Pharmacy, The University of Sydney, Pharmacy and Bank Building A15, NSW 2006, Australia.
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252
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Racial variations in extracorporeal membrane oxygenation use following congenital heart surgery. J Thorac Cardiovasc Surg 2018; 156:306-315. [PMID: 29681396 DOI: 10.1016/j.jtcvs.2018.02.103] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 02/09/2018] [Accepted: 02/15/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Previous studies demonstrate racial and ethnic disparities among children undergoing congenital heart surgery. Extracorporeal membrane oxygenation (ECMO) is used to support critically ill children after congenital heart surgery and improve survival. Thus, racial or ethnic variations in postoperative ECMO use following congenital heart surgery may be associated with racial/ethnic disparities in hospital survival. METHODS All children in the Pediatric Health Information Systems dataset undergoing congenital heart surgery from 2004 to 2015 were examined. Multivariable, multinomial regression models examining hospital survival without ECMO use, survival after ECMO, death after ECMO, and death without ECMO support were constructed. RESULTS Of 130,860 congenital cardiac surgery patients, 95.4% survived to hospital discharge without requiring ECMO support, whereas 1.3% survived after ECMO support, 1.3% died after ECMO support, and 1.9% died without receiving ECMO support. After adjustment for other covariates, black patients (odds ratio, 1.22; 95% confidence interval [CI], 1.05-1.42) and patients of other race (odds ratio, 1.36; 95% CI, 1.17-1.58) were at increased odds of mortality compared with white patients. In multivariable multinomial models, black patients had increased risk of death without ECMO support (relative risk, 1.31; 95% CI, 1.11-1.56). Patients of other race (relative risk, 1.37; 95% CI, 1.10-1.69) and governmental insurance (relative risk, 1.24; 95% CI, 1.12-1.37) were also at increased risk of death without ECMO. CONCLUSIONS Black children and children of other race are at increased odds of mortality after congenital heart surgery. These disparities can be traced to variations in ECMO utilization across racial/ethnic groups.
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Sukhera J, Milne A, Teunissen PW, Lingard L, Watling C. The Actual Versus Idealized Self: Exploring Responses to Feedback About Implicit Bias in Health Professionals. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2018; 93:623-629. [PMID: 29140915 DOI: 10.1097/acm.0000000000002006] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
PURPOSE Implicit bias can adversely affect health disparities. The implicit association test (IAT) is a prompt to stimulate reflection; however, feedback about bias may trigger emotions that reduce the effectiveness of feedback interventions. Exploring how individuals process feedback about implicit bias may inform bias recognition and management curricula. The authors sought to explore how health professionals perceive the influence of the experience of taking the IAT and receiving their results. METHOD Using constructivist grounded theory methodology, the authors conducted semistructured interviews with 21 pediatric physicians and nurses at the Schulich School of Medicine and Dentistry, Western University, Ontario, Canada, from September 2015 to November 2016 after they completed the mental illness IAT and received their result. Data were analyzed using constant comparative procedures to work toward axial coding and development of an explanatory theory. RESULTS When provided feedback about their implicit attitudes, participants described tensions between acceptance and justification, and between how IAT results relate to idealized and actual personal and professional identity. Participants acknowledged desire for change while accepting that change is difficult. Most participants described the experience of taking the IAT and receiving their result as positive, neutral, or interesting. CONCLUSIONS These findings contribute to emerging understandings of the relationship between emotions and feedback and may offer potential mediators to reconcile feedback that reveals discrepancies between an individual's actual and idealized identities. These results suggest that reflection informed by tensions between actual and aspirational aspects of professional identity may hold potential for implicit bias recognition and management curricula.
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Affiliation(s)
- Javeed Sukhera
- J. Sukhera is assistant professor of psychiatry and paediatrics and PhD candidate, Health Professions Education, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada. A. Milne is a nurse, paediatric medicine and child and adolescent psychiatry, London Health Sciences Centre, London, Ontario, Canada. P.W. Teunissen is associate professor of medical education, Maastricht University, Maastricht, the Netherlands, and gynecologist, VU University Medical Center, Amsterdam, the Netherlands. L. Lingard is professor, Department of Medicine, and director, Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada. C. Watling is associate dean for postgraduate medical education, Schulich School of Medicine and Dentistry, Western University, and scientist, Centre for Education Research and Innovation, London, Ontario, Canada
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Leslie KF, Sawning S, Shaw MA, Martin LJ, Simpson RC, Stephens JE, Jones VF. Changes in medical student implicit attitudes following a health equity curricular intervention. MEDICAL TEACHER 2018; 40:372-378. [PMID: 29171321 DOI: 10.1080/0142159x.2017.1403014] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
PURPOSE This study assessed the: (1) effect of an LGBTQI + health equity curriculum (eQuality) on implicit attitudes among first (M1) and second year (M2) medical students and (2) utility of dedicated time to explore implicit bias. METHOD Implicit biases were assessed at baseline using implicit association tests (IAT) for all M2s and a random sample of first years (M1A). These students were then debriefed on strategies to mitigate bias. Following eQuality, all M1 and M2s completed post-intervention IATs. The remaining first years (M1B) were then debriefed. Paired sample t-tests assessed differences between pre/post. Independent sample t-tests assessed differences in post-IATs between M1 groups. RESULTS IATs indicated preferences for "Straight," "White," and "Thin" at both pre and post. M2s demonstrated statistically significant improvements pre to post for sexuality (p = 0.01) and race (p = 0.03). There were significant differences in post-intervention IAT scores between M1As who received the IAT and debriefing prior to eQuality and M1Bs for sexuality (p = 0.002) and race (p = 0.046). There were no significant changes for weight. CONCLUSION eQuality reduced implicit preference for "Straight" and "White." Differences in M1 post-intervention IAT scores between groups suggest dedicating time to debrief implicit attitudes enhances bias mitigation.
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Affiliation(s)
- Katie F Leslie
- a Health Sciences Center Office of Diversity and Inclusion , University of Louisville , Louisville , KY , USA
| | - Susan Sawning
- a Health Sciences Center Office of Diversity and Inclusion , University of Louisville , Louisville , KY , USA
| | - M Ann Shaw
- a Health Sciences Center Office of Diversity and Inclusion , University of Louisville , Louisville , KY , USA
| | - Leslee J Martin
- a Health Sciences Center Office of Diversity and Inclusion , University of Louisville , Louisville , KY , USA
| | - Ryan C Simpson
- a Health Sciences Center Office of Diversity and Inclusion , University of Louisville , Louisville , KY , USA
| | - Jennifer E Stephens
- a Health Sciences Center Office of Diversity and Inclusion , University of Louisville , Louisville , KY , USA
| | - V Faye Jones
- a Health Sciences Center Office of Diversity and Inclusion , University of Louisville , Louisville , KY , USA
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McQuaid EL. Barriers to medication adherence in asthma: The importance of culture and context. Ann Allergy Asthma Immunol 2018; 121:37-42. [PMID: 29580846 DOI: 10.1016/j.anai.2018.03.024] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 03/12/2018] [Accepted: 03/19/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Significant disparities exist in asthma outcomes. Racial and ethnic minorities have lower controller medication adherence, which may contribute to differences in asthma morbidity between minority and non-minority groups. The objective of this review is to identify individual, patient-provider communication, and systems issues that contribute to this pattern of medication underuse and to discuss potential strategies for intervention. DATA SOURCES Data were gathered from numerous sources, including reports of pharmacy and medical records, observational studies, and trials. STUDY SELECTIONS Studies analyzed factors contributing to patterns of asthma medication adherence that differ by race and ethnicity. RESULTS There is clear evidence of underuse of asthma controller medications among racial and ethnic minorities in prescription receipt, prescription initiation, and medication use once obtained. Individual factors such as medication beliefs and depressive symptoms play a role. Provider communication is also relevant, including limited discussion of complementary and alternative medicine use, difficulties communicating with patients and caregivers with limited English proficiency, and implicit biases regarding cultural differences. Systems issues (eg, insurance status, cost) and social context factors (eg, exposure to violence) also present challenges. Culturally informed strategies that capitalize on patient strengths and training providers in culturally informed communication strategies hold promise as intervention approaches. CONCLUSION Disparities in controller medication use are pervasive. Identifying the sources of these disparities is a critical step toward generating intervention approaches to enhance disease management among the groups that bear the greatest asthma burden.
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Affiliation(s)
- Elizabeth L McQuaid
- Department of Psychiatry and Human Behavior, Alpert Medical School, Brown University, Providence, Rhode Island; Department of Pediatrics, Alpert Medical School, Brown University, Providence, Rhode Island.
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Maina IW, Belton TD, Ginzberg S, Singh A, Johnson TJ. A decade of studying implicit racial/ethnic bias in healthcare providers using the implicit association test. Soc Sci Med 2018; 199:219-229. [DOI: 10.1016/j.socscimed.2017.05.009] [Citation(s) in RCA: 327] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 05/01/2017] [Accepted: 05/03/2017] [Indexed: 12/12/2022]
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Harris R, Cormack D, Stanley J, Curtis E, Jones R, Lacey C. Ethnic bias and clinical decision-making among New Zealand medical students: an observational study. BMC MEDICAL EDUCATION 2018; 18:18. [PMID: 29361958 PMCID: PMC5782368 DOI: 10.1186/s12909-018-1120-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 01/08/2018] [Indexed: 05/14/2023]
Abstract
BACKGROUND Health professional racial/ethnic bias may impact on clinical decision-making and contribute to subsequent ethnic health inequities. However, limited research has been undertaken among medical students. This paper presents findings from the Bias and Decision-Making in Medicine (BDMM) study, which sought to examine ethnic bias (Māori (indigenous peoples) compared with New Zealand European) among medical students and associations with clinical decision-making. METHODS All final year New Zealand (NZ) medical students in 2014 and 2015 (n = 888) were invited to participate in a cross-sectional online study. Key components included: two chronic disease vignettes (cardiovascular disease (CVD) and depression) with randomized patient ethnicity (Māori or NZ European) and questions on patient management; implicit bias measures (an ethnicity preference Implicit Association Test (IAT) and an ethnicity and compliant patient IAT); and, explicit ethnic bias questions. Associations between ethnic bias and clinical decision-making responses to vignettes were tested using linear regression. RESULTS Three hundred and two students participated (34% response rate). Implicit and explicit ethnic bias favoring NZ Europeans was apparent among medical students. In the CVD vignette, no significant differences in clinical decision-making by patient ethnicity were observed. There were also no differential associations by patient ethnicity between any measures of ethnic bias (implicit or explicit) and patient management responses in the CVD vignette. In the depression vignette, some differences in the ranking of recommended treatment options were observed by patient ethnicity and explicit preference for NZ Europeans was associated with increased reporting that NZ European patients would benefit from treatment but not Māori (slope difference 0.34, 95% CI 0.08, 0.60; p = 0.011), although this was the only significant finding in these analyses. CONCLUSIONS NZ medical students demonstrated ethnic bias, although overall this was not associated with clinical decision-making. This study both adds to the small body of literature internationally on racial/ethnic bias among medical students and provides relevant and important information for medical education on indigenous health and ethnic health inequities in New Zealand.
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Affiliation(s)
- Ricci Harris
- Te Kupenga Hauora Māori, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland, 1142 New Zealand
| | - Donna Cormack
- Te Kupenga Hauora Māori, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland, 1142 New Zealand
| | - James Stanley
- Biostatistics Group, Dean’s Department, University of Otago Wellington, PO Box 7343, Wellington, 6242 New Zealand
| | - Elana Curtis
- Te Kupenga Hauora Māori, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland, 1142 New Zealand
| | - Rhys Jones
- Te Kupenga Hauora Māori, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland, 1142 New Zealand
| | - Cameron Lacey
- Māori/Indigenous Health Institute (MIHI), University of Otago Christchurch, PO Box 4345, Christchurch, 8140 New Zealand
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Weber L, Zambrana RE, Fore ME, Parra-Medina D. Racial and Ethnic Health Inequities: An Intersectional Approach. HANDBOOKS OF SOCIOLOGY AND SOCIAL RESEARCH 2018. [DOI: 10.1007/978-3-319-76757-4_8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Dossey L. The Shock of Charlottesville: Unmasking Racism in Healthcare. Explore (NY) 2018; 14:1-9. [DOI: 10.1016/j.explore.2017.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hernandez R. Medical Students' Implicit Bias and the Communication of Norms in Medical Education. TEACHING AND LEARNING IN MEDICINE 2018; 30:112-117. [PMID: 29240453 DOI: 10.1080/10401334.2017.1359610] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 05/07/2017] [Accepted: 05/30/2017] [Indexed: 06/07/2023]
Abstract
ISSUE Medical educators should consider how institutional norms influence medical students' perceptions of implicit bias. Understanding normative structures in medical education can shed light on why this influence is associated with students' resistance to implicit bias. EVIDENCE Extant research across diverse fields of study uncovers and theorizes layers of norms and normative systems and how they are related to ethical behavior. This review bridges the fields of communication, bioethics, and medical education, constructing an organized foundation and common language by which researchers can build effective educational interventions. First, the nature and effects of implicit bias are described. Second, the nature of normative systems in medical education is explicated. Concepts from the fields of education and communication are transferred to medical education. Third, the structure of the communication of norms in medical education is revealed, through theoretical research in bioethics and empirical medical education research. IMPLICATIONS Recommendations are provided for medical educators to improve activities intended to encourage reflection on implicit bias. These recommendations include reframing educational activities as endeavors in "personal" development and uncovering and transforming those normative structures that encourage resistance to implicit bias.
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Affiliation(s)
- Rachael Hernandez
- a Department of Communication Studies , Indiana University-Purdue University Indianapolis , Indianapolis , Indiana , USA
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Sukhera J, Watling C. A Framework for Integrating Implicit Bias Recognition Into Health Professions Education. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2018; 93:35-40. [PMID: 28658015 DOI: 10.1097/acm.0000000000001819] [Citation(s) in RCA: 129] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Existing literature on implicit bias is fragmented and comes from a variety of fields like cognitive psychology, business ethics, and higher education, but implicit-bias-informed educational approaches have been underexplored in health professions education and are difficult to evaluate using existing tools. Despite increasing attention to implicit bias recognition and management in health professions education, many programs struggle to meaningfully integrate these topics into curricula. The authors propose a six-point actionable framework for integrating implicit bias recognition and management into health professions education that draws on the work of previous researchers and includes practical tools to guide curriculum developers. The six key features of this framework are creating a safe and nonthreatening learning context, increasing knowledge about the science of implicit bias, emphasizing how implicit bias influences behaviors and patient outcomes, increasing self-awareness of existing implicit biases, improving conscious efforts to overcome implicit bias, and enhancing awareness of how implicit bias influences others. Important considerations for designing implicit-bias-informed curricula-such as individual and contextual variables, as well as formal and informal cultural influences-are discussed. The authors also outline assessment and evaluation approaches that consider outcomes at individual, organizational, community, and societal levels. The proposed framework may facilitate future research and exploration regarding the use of implicit bias in health professions education.
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Affiliation(s)
- Javeed Sukhera
- J. Sukhera is assistant professor of psychiatry and pediatrics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada, and PhD candidate in health professions education, Maastricht University, Maastricht, the Netherlands; ORCID: http://orcid.org/0000-0001-8146-4947. C. Watling is associate dean for postgraduate medical education and scientist, Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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Tajeu GS, Halanych J, Juarez L, Stone J, Stepanikova I, Green A, Cherrington AL. Exploring the Association of Healthcare Worker Race and Occupation with Implicit and Explicit Racial Bias. J Natl Med Assoc 2017; 110:464-472. [PMID: 30129512 DOI: 10.1016/j.jnma.2017.12.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 10/31/2017] [Accepted: 12/01/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Racial bias is associated with suboptimal healthcare treatment for minorities. Research focuses on bias among physicians rather than non-physician healthcare staff (e.g., receptionists). Patients spend considerable amounts of time with non-physician staff. Therefore, we investigate differences in implicit and explicit racial bias by healthcare staff race and occupation using the Implicit Association Test and Modern Racism Scale, respectively. METHODS Staff (n = 107) were recruited using the Alabama based Primary Care Research Coalition. Occupation was categorized into "medical doctors/registered nurses" (MD/RN) and "non-MD/RN" (e.g., receptionists). RESULTS Implicit bias scores were higher among whites compared with blacks (0.62, -0.04, respectively; p < 0.01). Among whites, non-MD/RNs demonstrated more pro-white implicit bias compared with MD/RNs (0.67, 0.44, respectively; p < 0.01). Whites had higher explicit bias scores than blacks (17.7, 12.3, respectively; p < 0.01). CONCLUSION Non-MD/RNs should not be overlooked for cultural competency training, and efforts are needed to reduce racial bias among healthcare workers identified as having higher levels of bias.
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Affiliation(s)
- Gabriel S Tajeu
- Department of Health Services Administration and Policy, Temple University, Philadelphia, PA, USA.
| | - Jewell Halanych
- Department of Internal Medicine, Montgomery Campus of the University of Alabama School of Medicine, Montgomery, AL, USA
| | - Lucia Juarez
- 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, USA
| | - Irena Stepanikova
- Department of Sociology, University of Alabama at Birmingham and Research Centre for Toxic Compounds in the Environment, Masaryk University, Birmingham, AL, Czech Republic
| | - Alexander Green
- The Disparities Solutions Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrea L Cherrington
- Division of Preventive Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Eggly S, Hamel LM, Heath E, Manning MA, Albrecht TL, Barton E, Wojda M, Foster T, Carducci M, Lansey D, Wang T, Abdallah R, Abrahamian N, Kim S, Senft N, Penner LA. Partnering around cancer clinical trials (PACCT): study protocol for a randomized trial of a patient and physician communication intervention to increase minority accrual to prostate cancer clinical trials. BMC Cancer 2017; 17:807. [PMID: 29197371 PMCID: PMC5712160 DOI: 10.1186/s12885-017-3804-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 11/21/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Cancer clinical trials are essential for testing new treatments and represent state-of-the-art cancer treatment, but only a small percentage of patients ever enroll in a trial. Under-enrollment is an even greater problem among minorities, particularly African Americans, representing a racial/ethnic disparity in cancer care. One understudied cause is patient-physician communication, which is often of poor quality during clinical interactions between African-American patients and non-African-American physicians. Partnering Around Cancer Clinical Trials (PACCT) involves a transdisciplinary theoretical model proposing that patient and physician individual attitudes and beliefs and their interpersonal communication during racially discordant clinical interactions influence outcomes related to patients' decisions to participate in a trial. The overall goal of the study is to test a multilevel intervention designed to increase rates at which African-American and White men with prostate cancer make an informed decision to participate in a clinical trial. METHODS/DESIGN Data collection will occur at two NCI-designated comprehensive cancer centers. Participants include physicians who treat men with prostate cancer and their African-American and White patients who are potentially eligible for a clinical trial. The study uses two distinct research designs to evaluate the effects of two behavioral interventions, one focused on patients and the other on physicians. The primary goal is to increase the number of patients who decide to enroll in a trial; secondary goals include increasing rates of physician trial offers, improving the quality of patient-physician communication during video recorded clinical interactions in which trials may be discussed, improving patients' understanding of trials offered, and increasing the number of patients who actually enroll. Aims are to 1) determine the independent and combined effects of the two interventions on outcomes; 2) compare the effects of the interventions on African-American versus White men; and 3) examine the extent to which patient-physician communication mediates the effect of the interventions on the outcomes. DISCUSSION PACCT has the potential to identify ways to increase clinical trial rates in a diverse patient population. The research can also improve access to high quality clinical care for African American men bearing the disproportionate burden of disparities in prostate and other cancers. TRIAL REGISTRATION Clinical Trials.gov registration number: NCT02906241 (September 8, 2016).
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Affiliation(s)
- Susan Eggly
- Department of Oncology, Wayne State University/Karmanos Cancer Institute, 4100 John R, Detroit, MI 48201 USA
| | - Lauren M. Hamel
- Department of Oncology, Wayne State University/Karmanos Cancer Institute, 4100 John R, Detroit, MI 48201 USA
| | - Elisabeth Heath
- Department of Oncology, Wayne State University/Karmanos Cancer Institute, 4100 John R, Detroit, MI 48201 USA
| | - Mark A. Manning
- Department of Oncology, Wayne State University/Karmanos Cancer Institute, 4100 John R, Detroit, MI 48201 USA
| | - Terrance L. Albrecht
- Department of Oncology, Wayne State University/Karmanos Cancer Institute, 4100 John R, Detroit, MI 48201 USA
| | - Ellen Barton
- Department of English, Wayne State University, 5057 Woodward Suite 9408, Detroit, MI 48202 USA
| | - Mark Wojda
- Department of Oncology, Wayne State University/Karmanos Cancer Institute, 4100 John R, Detroit, MI 48201 USA
| | - Tanina Foster
- Department of Oncology, Wayne State University/Karmanos Cancer Institute, 4100 John R, Detroit, MI 48201 USA
| | - Michael Carducci
- Johns Hopkins School of Medicine/Sidney Kimmel Comprehensive Cancer Center, 1M59 Bunting –Blaustein Cancer Research Building, 1650 Orleans Street, Baltimore, MD 21287 USA
| | - Dina Lansey
- Johns Hopkins School of Medicine/Sidney Kimmel Comprehensive Cancer Center, 550 North Broadway, 1003-G, Baltimore, MD 21205 USA
| | - Ting Wang
- Johns Hopkins School of Medicine/Sidney Kimmel Comprehensive Cancer Center, 550 North Broadway, 1003-G, Baltimore, MD 21205 USA
| | - Rehab Abdallah
- Johns Hopkins School of Medicine/Sidney Kimmel Comprehensive Cancer Center, 550 North Broadway, 1003-G, Baltimore, MD 21205 USA
| | - Narineh Abrahamian
- Johns Hopkins School of Medicine/Sidney Kimmel Comprehensive Cancer Center, 550 North Broadway, 1003-G, Baltimore, MD 21205 USA
| | - Seongho Kim
- Department of Oncology, Wayne State University/Karmanos Cancer Institute, 4100 John R, Detroit, MI 48201 USA
| | - Nicole Senft
- Department of Oncology, Wayne State University/Karmanos Cancer Institute, 4100 John R, Detroit, MI 48201 USA
| | - Louis A. Penner
- Department of Oncology, Wayne State University/Karmanos Cancer Institute, 4100 John R, Detroit, MI 48201 USA
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Phelan SM, Burke SE, Hardeman RR, White RO, Przedworski J, Dovidio JF, Perry SP, Plankey M, A Cunningham B, Finstad D, W Yeazel M, van Ryn M. Medical School Factors Associated with Changes in Implicit and Explicit Bias Against Gay and Lesbian People among 3492 Graduating Medical Students. J Gen Intern Med 2017; 32:1193-1201. [PMID: 28766125 PMCID: PMC5653554 DOI: 10.1007/s11606-017-4127-6] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 05/25/2017] [Accepted: 06/23/2017] [Indexed: 10/19/2022]
Abstract
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.
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Affiliation(s)
- Sean M Phelan
- Division of Healthcare Policy and Research, Mayo Clinic, Rochester, MN, USA.
| | - Sara E Burke
- Department of Psychology, Yale University, New Haven, CT, USA
| | - Rachel R Hardeman
- Division of Health Policy and Management, University of Minnesota, Minneapolis, MN, USA
| | - Richard O White
- Division of Community Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Julia Przedworski
- Division of Health Policy and Management, University of Minnesota, Minneapolis, MN, USA
| | - John F Dovidio
- Department of Psychology, Yale University, New Haven, CT, USA
| | - Sylvia P Perry
- Department of Psychology, Northwestern University, Evanston, IL, USA
| | - Michael Plankey
- Division of Infectious Diseases, Department of Medicine, Georgetown University Medical School, Washington, DC, USA
| | - Brooke A Cunningham
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Deborah Finstad
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Mark W Yeazel
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Michelle van Ryn
- Division of Healthcare Policy and Research, Mayo Clinic, Rochester, MN, USA
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Talwar A, Garcia JGN, Tsai H, Moreno M, Lahm T, Zamanian RT, Machado R, Kawut SM, Selej M, Mathai S, D'Anna LH, Sahni S, Rodriquez EJ, Channick R, Fagan K, Gray M, Armstrong J, Rodriguez Lopez J, de Jesus Perez V. Health Disparities in Patients with Pulmonary Arterial Hypertension: A Blueprint for Action. An Official American Thoracic Society Statement. Am J Respir Crit Care Med 2017; 196:e32-e47. [PMID: 29028375 DOI: 10.1164/rccm.201709-1821st] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Health disparities have a major impact in the quality of life and clinical care received by minorities in the United States. Pulmonary arterial hypertension (PAH) is a rare cardiopulmonary disorder that affects children and adults and that, if untreated, results in premature death. The impact of health disparities in the diagnosis, treatment, and clinical outcome of patients with PAH has not been systematically investigated. OBJECTIVES The specific goals of this research statement were to conduct a critical review of the literature concerning health disparities in PAH, identify major research gaps and prioritize direction for future research. METHODS Literature searches from multiple reference databases were performed using medical subject headings and text words for pulmonary hypertension and health disparities. Members of the committee discussed the evidence and provided recommendations for future research. RESULTS Few studies were found discussing the impact of health disparities in PAH. Using recent research statements focused on health disparities, the group identified six major study topics that would help address the contribution of health disparities to PAH. Representative studies in each topic were discussed and specific recommendations were made by the group concerning the most urgent questions to address in future research studies. CONCLUSIONS At present, there are few studies that address health disparities in PAH. Given the potential adverse impact of health disparities, we recommend that research efforts be undertaken to address the topics discussed in the document. Awareness of health disparities will likely improve advocacy efforts, public health policy and the quality of care of vulnerable populations with PAH.
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268
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Harper MB. Doing More About Health Care Disparities: Moving Past Description to Action. Pediatrics 2017; 140:peds.2017-2185. [PMID: 28872047 DOI: 10.1542/peds.2017-2185] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/21/2017] [Indexed: 11/24/2022] Open
Affiliation(s)
- Marvin B Harper
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
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269
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Penner LA, Harper FWK, Dovidio JF, Albrecht TL, Hamel LM, Senft N, Eggly S. The impact of Black cancer patients' race-related beliefs and attitudes on racially-discordant oncology interactions: A field study. Soc Sci Med 2017; 191:99-108. [PMID: 28917141 PMCID: PMC5706115 DOI: 10.1016/j.socscimed.2017.08.034] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 08/16/2017] [Accepted: 08/25/2017] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Both physician and patient race-related beliefs and attitudes are contributors to racial healthcare disparities, but only the former have received substantial research attention. Using data from a study conducted in the Midwestern US from 2012 to 2014, we investigated whether 114 Black cancer patients' existing race-related beliefs and attitudes would predict how they and 18 non-Black physicians (medical oncologists) would respond in subsequent clinical interactions. METHOD At least two days before interacting with an oncologist for initial discussions of treatment options, patients completed measures of perceived past discrimination, general mistrust of physicians, and suspicion of healthcare systems; interactions were video-recorded. Measures from each interaction included patients' verbal behavior (e.g., level of verbal activity), patients' evaluations of physicians (e.g., trustworthiness), patients' perceptions of recommended treatments (e.g., confidence in treatment), physicians' evaluations of patient personal attributes (e.g., intelligence) and physicians' expectations for patient treatment success (e.g., adherence). RESULTS As predicted, patients' race-related beliefs and attitudes differed in their associations with patient and physician responses to the interactions. Higher levels of perceived past discrimination predicted more patient verbal activity. Higher levels of mistrust also predicted less patient positive affect and more negative evaluations of physicians. Higher levels of suspicion predicted more negative evaluations of physicians and recommended treatments. Stronger patient race-related attitudes were directly or indirectly associated with lower physician perceptions of patient attributes and treatment expectations. CONCLUSION Results provide new evidence for the role of Black patients' race-related beliefs and attitudes in racial healthcare disparities and suggest the need to measure multiple beliefs and attitudes to identify these effects.
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Affiliation(s)
- Louis A Penner
- Department of Oncology, Wayne State University, Karmanos Cancer Institute, United States.
| | - Felicity W K Harper
- Department of Oncology, Wayne State University, Karmanos Cancer Institute, United States
| | - John F Dovidio
- Department of Psychology, Yale University, United States
| | - Terrance L Albrecht
- Department of Oncology, Wayne State University, Karmanos Cancer Institute, United States
| | - Lauren M Hamel
- Department of Oncology, Wayne State University, Karmanos Cancer Institute, United States
| | - Nicole Senft
- Department of Oncology, Wayne State University, Karmanos Cancer Institute, United States
| | - Susan Eggly
- Department of Oncology, Wayne State University, Karmanos Cancer Institute, United States
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270
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Xu HF, White RS, Sastow DL, Andreae MH, Gaber-Baylis LK, Turnbull ZA. Medicaid insurance as primary payer predicts increased mortality after total hip replacement in the state inpatient databases of California, Florida and New York. J Clin Anesth 2017; 43:24-32. [PMID: 28972923 DOI: 10.1016/j.jclinane.2017.09.008] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 08/31/2017] [Accepted: 09/23/2017] [Indexed: 12/21/2022]
Abstract
STUDY OBJECTIVE To confirm the relationship between primary payer status as a predictor of increased perioperative risks and post-operative outcomes after total hip replacements. DESIGN Retrospective cohort study. SETTING Administrative database study using 2007-2011 data from California, Florida, and New York from the State Inpatient Databases (SID), Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. PATIENTS 295,572 patients age≥18years old who underwent total hip replacement with non-missing insurance data were collected, using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnoses and procedures code (ICD-9-CM code 81.51). INTERVENTIONS Patients underwent total hip replacement. MEASUREMENTS Patients were cohorted by insurance type as either Medicare, Medicaid, Uninsured, Other, and Private Insurance. Demographic characteristics and comorbidities were compared. Unadjusted rates of in-hospital mortality, postoperative complications, LOS, 30-day, and 90-day readmission status were compared. Adjusted odds ratios were calculated for our outcomes using multivariate linear and logistic regression models fitted to our data. MAIN RESULTS Medicaid patients incurred a 125% increase in the odds of in-hospital mortality compared to those with Private Insurance (OR 2.25, 99% CI 1.01-5.01). Medicaid payer status was associated with the highest statistically significant adjusted odds of mortality, any complication (OR, 1.26), cardiovascular complications (OR, 1.37), and infectious complications (OR, 1.66) when compared with Private Insurance. Medicaid patients had the highest statistically significant adjusted odds of 30-day (OR, 1.63) and 90-day readmission (OR, 1.58) and the longest adjusted LOS. CONCLUSIONS We found higher unadjusted rates and risk adjusted odds ratios of postoperative mortality, morbidity, LOS, and readmissions for patients with Medicaid insurance as compared to patients with Private Insurance. Our study shows that primary payer status serves as a predictor of perioperative risks and that primary payer status should be viewed as a peri-operative risk factor.
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Affiliation(s)
- Hannah F Xu
- New York Presbyterian Hospital- Weill Cornell Medicine, Department of Anesthesiology, 525 East 68th Street, Box 124, New York, NY 10065, USA.
| | - Robert S White
- New York Presbyterian Hospital- Weill Cornell Medicine, Department of Anesthesiology, 525 East 68th Street, Box 124, New York, NY 10065, USA.
| | - Dahniel L Sastow
- Weill Cornell Medicine Center for Perioperative Outcomes, 428 East 72nd St., Ste 800A, New York, NY 10021, USA.
| | - Michael H Andreae
- Penn State Milton S. Hershey Medical Center, 500 University Drive, H187, Hershey, PA 17033, USA.
| | - Licia K Gaber-Baylis
- Weill Cornell Medicine Center for Perioperative Outcomes, 428 East 72nd St., Ste 800A, New York, NY 10021, USA.
| | - Zachary A Turnbull
- New York Presbyterian Hospital- Weill Cornell Medicine, Department of Anesthesiology, 525 East 68th Street, Box 124, New York, NY 10065, USA.
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271
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Dehon E, Weiss N, Jones J, Faulconer W, Hinton E, Sterling S. A Systematic Review of the Impact of Physician Implicit Racial Bias on Clinical Decision Making. Acad Emerg Med 2017; 24:895-904. [PMID: 28472533 DOI: 10.1111/acem.13214] [Citation(s) in RCA: 230] [Impact Index Per Article: 32.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 04/19/2017] [Accepted: 04/26/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Disparities in diagnosis and treatment of racial minorities exist in the emergency department (ED). A better understanding of how physician implicit (unconscious) bias contributes to these disparities may help identify ways to eliminate such racial disparities. The objective of this systematic review was to examine and summarize the evidence on the association between physician implicit racial bias and clinical decision making. METHODS Based on PRISMA guidelines, a structured electronic literature search of PubMed, CINAHL, Scopus, and PsycINFO databases was conducted. Eligible studies were those that: 1) included physicians, 2) included the Implicit Association Test as a measure of implicit bias, 3) included an assessment of physician clinical decision making, and 4) were published in peer-reviewed journals between 1998 and 2016. Articles were reviewed for inclusion by two independent investigators. Data extraction was performed by one investigator and checked for accuracy by a second investigator. Two investigators independently scored the quality of articles using a modified version of the Downs and Black checklist. RESULTS Of the 1,154 unique articles identified in the initial search, nine studies (n = 1,910) met inclusion criteria. Three of the nine studies involved emergency providers including residents, attending physicians, and advanced practice providers. The majority of studies used clinical vignettes to examine clinical decision making. Studies that included emergency medicine (EM) providers had vignettes relating to treatment of acute myocardial infarction, pain, and pediatric asthma. An implicit preference favoring white people was common across providers, regardless of specialty. Two of the nine studies found evidence of a relationship between implicit bias and clinical decision making; one of these studies included EM providers. This one study found that EM and internal medicine residents who demonstrated an implicit preference for white individuals were more likely to treat white patients and not black patients with thrombolysis for myocardial infarction. Evidence from the two studies reporting a relationship between physician implicit racial bias and decision making was low in quality. CONCLUSIONS The current literature indicates that although many physicians, regardless of specialty, demonstrate an implicit preference for white people, this bias does not appear to impact their clinical decision making. Further studies on the impact of implicit racial bias on racial disparities in ED treatment are needed.
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Affiliation(s)
- Erin Dehon
- Department of Emergency Medicine; University of Mississippi Medical Center; Jackson MI
| | - Nicole Weiss
- Department of Psychiatry; Yale University School of Medicine; New Haven CT
| | - Jonathan Jones
- Department of Emergency Medicine; University of Mississippi Medical Center; Jackson MI
| | - Whitney Faulconer
- Department of Emergency Medicine; University of Mississippi Medical Center; Jackson MI
| | - Elizabeth Hinton
- Rowland Medical Library; University of Mississippi Medical Center; Jackson MI
| | - Sarah Sterling
- Department of Emergency Medicine; University of Mississippi Medical Center; Jackson MI
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Finnegan MA, Shaffer R, Remington A, Kwong J, Curtin C, Hernandez-Boussard T. Emergency Department Visits Following Elective Total Hip and Knee Replacement Surgery: Identifying Gaps in Continuity of Care. J Bone Joint Surg Am 2017. [PMID: 28632589 DOI: 10.2106/jbjs.16.00692] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Major joint replacement surgical procedures are common, elective procedures with a care episode that includes both inpatient readmissions and postoperative emergency department (ED) visits. Inpatient readmissions are well studied; however, to our knowledge, little is known about ED visits following these procedures. We sought to characterize 30-day ED visits following a major joint replacement surgical procedure. METHODS We used administrative records from California, Florida, and New York, from 2010 through 2012, to identify adults undergoing total knee and hip arthroplasty. Factors associated with increased risk of an ED visit were estimated using hierarchical regression models controlling for patient variables with a fixed hospital effect. The main outcome was an ED visit within 30 days of discharge. RESULTS Among the 152,783 patients who underwent major joint replacement, 5,229 (3.42%) returned to the inpatient setting and 8,883 (5.81%) presented to the ED for care within 30 days. Among ED visits, 17.94% had a primary diagnosis of pain and 25.75% had both a primary and/or a secondary diagnosis of pain. Patients presenting to the ED for subsequent care had more comorbidities and were more frequently non-white with public insurance relative to those not returning to the ED (p < 0.001). There was a significantly increased risk (p < 0.05) of isolated ED visits with regard to type of insurance when patients with Medicaid (odds ratio [OR], 2.28 [95% confidence interval (CI), 2.04 to 2.55]) and those with Medicare (OR, 1.38 [95% CI, 1.29 to 1.47]) were compared with patients with private insurance and with regard to race when black patients (OR, 1.38 [95% CI, 1.25 to 1.53]) and Hispanic patients (OR, 1.12 [95% CI, 1.03 to 1.22]) were compared with white patients. These increases in risk were stronger for isolated ED visits for patients with a pain diagnosis. CONCLUSIONS ED visits following an elective major joint replacement surgical procedure were numerous and most commonly for pain-related diagnoses. Medicaid patients had almost double the risk of an ED or pain-related ED visit following a surgical procedure. The future of U.S. health-care insurance coverage expansions are uncertain; however, there are ongoing attempts to improve quality across the continuum of care. It is therefore essential to ensure that all patients, particularly vulnerable populations, receive appropriate postoperative care, including pain management. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Micaela A Finnegan
- 1Departments of Medicine (M.A.F., R.S., A.R., J.K., and T.H.-B.) and Surgery (C.C.), Stanford University School of Medicine, Stanford, California 2Department of Surgery, VA Palo Alto Health Care System, Palo Alto, California
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273
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Hunnicutt JN, Ulbricht CM, Tjia J, Lapane KL. Pain and pharmacologic pain management in long-stay nursing home residents. Pain 2017; 158:1091-1099. [PMID: 28267065 PMCID: PMC5435509 DOI: 10.1097/j.pain.0000000000000887] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Previous studies estimate that >40% of long-stay nursing home (NH) residents experience persistent pain, with 20% of residents in pain receiving no analgesics. Strengthened NH surveyor guidance and improved pain measures on the Minimum Data Set 3.0 were introduced in March 2009 and October 2010, respectively. This study aimed to provide estimates after the important initiatives of (1) prevalence and correlates of persistent pain; and (2) prevalence and correlates of untreated or undertreated persistent pain. We identified 1,387,405 long-stay residents in U.S. NHs between 2011 and 2012 with 2 Minimum Data Set assessments 90 days apart. Pain was categorized as persistent (pain on both assessments), intermittent (pain on either assessment), or none. Pharmacologic pain management was classified as untreated pain (no scheduled or as needed medications received) or potentially undertreated (no scheduled received). Modified Poisson models adjusting for resident clustering within NHs provided adjusted prevalence ratios (APRs) estimates and 95% confidence intervals (CIs). The prevalence of persistent and intermittent pain was 19.5% and 19.2%, respectively, but varied substantially by age, sex, race and ethnicity, cognitive impairment, and cancer. Of residents in persistent pain, 6.4% and 32.0% were untreated and undertreated, respectively. Racial and ethnic minorities (non-Hispanic blacks vs whites, APR = 1.19, 95% CI: 1.13-1.25) and severely cognitively impaired residents (severe vs no/mild APR = 1.51, 95% CI: 1.44-1.57) had an increased prevalence of untreated and undertreated pain. One in 5 NH residents has persistent pain. Although this estimate is greatly improved, many residents may be undertreated. The disturbing disparities in untreated and undertreated pain need to be addressed.
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Affiliation(s)
- Jacob N Hunnicutt
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
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274
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Redman RM, Reinsvold MC, Reddy A, Bennett PE, Hoerauf JM, Puls KM, Ovrutsky AR, Ly AR, White G, McNeil O, Meredith JJ. A successful model for longitudinal community-engaged health research: the 2040 Partners for Health Student Program. Fam Pract 2017; 34:341-346. [PMID: 28407068 PMCID: PMC6390419 DOI: 10.1093/fampra/cmx025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Introduction Community-based participatory research [CBPR] is an emerging approach to collaborative research aimed at creating locally effective and sustainable interventions. The 2040 Partners for Health student program was developed as a unique model of longitudinal CBPR. Analysis of this program and its components illuminates both the challenges and the opportunities inherent in community engagement. Methods The program rests on a foundation of a community-based, non-profit organization and a supportive academic university centre. Inter-professional health students and community members of underserved populations work together on different health projects by employing an adapted CBPR methodology. Three successful examples of sustainable CBPR projects are briefly described. Results The three projects are presented as primary outcomes resulting from this model. Benefits and challenges of the model as an approach to community-engaged research are discussed as well as secondary benefits of student participation. Conclusion The 2040 Partners for Health student program represents a successful model of CBPR, illuminating common challenges and reiterating the profound value of community-engaged research.
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Affiliation(s)
| | | | - Anireddy Reddy
- School of Medicine, University of Colorado, Aurora, CO, USA
| | | | | | | | | | - Alexandra R Ly
- School of Medicine, University of Colorado, Aurora, CO, USA
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Abstract
OBJECTIVES Previous studies have suggested an association between nonwhite race and poor outcomes in small subsets of cardiac surgery patients who require extracorporeal life support. This study aims to examine the association of race/ethnicity with mortality in pediatric patients who receive extracorporeal life support for cardiac support. DESIGN Retrospective analysis of registry data. SETTING Prospectively collected multi-institutional registry data. SUBJECTS Data from all North American pediatric patients in the Extracorporeal Life Support International Registry who received extracorporeal life support for cardiac support between 1998 and 2012 were analyzed. Multivariate regression models were constructed to examine the association between race/ethnicity and hospital mortality, adjusting for demographics, diagnosis, pre-extracorporeal life support care, extracorporeal life support variables, and extracorporeal life support-related complications. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 7,106 patients undergoing cardiac extracorporeal life support, the majority of patients were of white race (56.9%) with black race (16.7%), Hispanic ethnicity (15.8%), and Asian race (2.8%) comprising the other major race/ethnic groups. The mortality rate was 53.9% (n = 3,831). After adjusting for covariates, multivariate analysis identified black race (relative risk = 1.10; 95% CI, 1.04-1.16) and Hispanic ethnicity (relative risk = 1.08; 95% CI, 1.02-1.14) as independent risk factors for mortality. CONCLUSIONS Black race and Hispanic ethnicity are independently associated with mortality in children who require cardiac extracorporeal life support.
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Abstract
BACKGROUND American Indian children have high rates of emergency department (ED) use and face potential discrimination in health care settings. OBJECTIVE Our goal was to assess both implicit and explicit racial bias and examine their relationship with clinical care. RESEARCH DESIGN We performed a cross-sectional survey of care providers at 5 hospitals in the Upper Midwest. Questions included American Indian stereotypes (explicit attitudes), clinical vignettes, and the Implicit Association Test. Two Implicit Association Tests were created to assess implicit bias toward the child or the parent/caregiver. Differences were assessed using linear and logistic regression models with a random effect for study site. RESULTS A total of 154 care providers completed the survey. Agreement with negative American Indian stereotypes was 22%-32%. Overall, 84% of providers had an implicit preference for non-Hispanic white adults or children. Older providers (50 y and above) had lower implicit bias than those middle aged (30-49 y) (P=0.01). American Indian children were seen as increasingly challenging (P=0.04) and parents/caregivers less compliant (P=0.002) as the proportion of American Indian children seen in the ED increased. Responses to the vignettes were not related to implicit or explicit bias. CONCLUSIONS The majority of ED care providers had an implicit preference for non-Hispanic white children or adults compared with those who were American Indian. Provider agreement with negative American Indian stereotypes differed by practice and respondents' characteristics. These findings require additional study to determine how these implicit and explicit biases influence health care or outcomes disparities.
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277
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Outcomes Following Surgical Management of Cauda Equina Syndrome: Does Race Matter? J Racial Ethn Health Disparities 2017; 5:287-292. [DOI: 10.1007/s40615-017-0369-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 03/29/2017] [Accepted: 04/03/2017] [Indexed: 01/21/2023]
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Johnson TJ, Ellison AM, Dalembert G, Fowler J, Dhingra M, Shaw K, Ibrahim S. Implicit Bias in Pediatric Academic Medicine. J Natl Med Assoc 2017; 109:156-163. [PMID: 28987244 PMCID: PMC5710818 DOI: 10.1016/j.jnma.2017.03.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 01/31/2017] [Accepted: 03/12/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Despite known benefits of diversity, certain racial/ethnic groups remain underrepresented in academic pediatrics. Little research exists regarding unconscious racial attitudes among pediatric faculty responsible for decisions on workforce recruitment and retention in academia. This study sought to describe levels of unconscious racial bias and perceived barriers to minority recruitment and retention among academic pediatric faculty leaders. METHODS Authors measured unconscious racial bias in a sample of pediatric faculty attending diversity workshops conducted at local and national meetings in 2015. A paper version of the validated Implicit Association Test (IAT) measured unconscious racial bias. Subjects also reported perceptions about minority recruitment and retention. RESULTS Of 68 eligible subjects approached, 58 (85%) consented and completed the survey with IAT. Of participants, 83% had leadership roles and 93% were involved in recruitment. Participants had slight pro-white/anti-black bias on the IAT (M = 0.28, SD = 0.49). There were similar IAT scores among participants in leadership roles (M = 0.33, SD = 0.47) and involved in recruitment (M = 0.28, SD = 0.43). Results did not differ when comparing participants in local workshops to the national workshop (n = 36, M = 0.29, SD = 0.40 and n = 22, M = 0.27, SD = 0.49 respectively; p = 0.88). Perceived barriers to minority recruitment and retention included lack of minority mentors, poor recruitment efforts, and lack of qualified candidates. CONCLUSIONS Unconscious pro-white/anti-black racial bias was identified in this sample of academic pediatric faculty and leaders. Further research is needed to examine how unconscious bias impacts decisions in academic pediatric workforce recruitment. Addressing unconscious bias and perceived barriers to minority recruitment and retention represent opportunities to improve diversity efforts.
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Affiliation(s)
- Tiffani J. Johnson
- Division of Emergency Medicine, PolicyLab, and Center for Perinatal and Pediatric Health Disparities Research, Children’s Hospital of Philadelphia; and Department of Pediatrics, University of Pennsylvania School of Medicine, 3535 Market Street Room 1425, Philadelphia, PA 19104
| | - Angela M. Ellison
- Division of Emergency Medicine, Children’s Hospital of Philadelphia; and Department of Pediatrics, University of Pennsylvania School of Medicine, 3401 Civic Center Boulevard, Philadelphia PA 19104
| | - George Dalembert
- Division of Medical Affairs, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104
| | - Jessica Fowler
- Division of Medical Affairs, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104
| | - Menaka Dhingra
- Division of Hematology, Children’s Hospital of Philadelphia, 3501 Civic Center Boulevard, Philadelphia, PA 19104
| | - Kathy Shaw
- Division of Emergency Medicine, Children’s Hospital of Philadelphia; and Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, 3501Civic Center Boulevard, Philadelphia, PA 19104
| | - Said Ibrahim
- Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine; and Director, Philadelphia VA Center for Health Equity Research & Promotion, 3900 Woodland Avenue, Philadelphia, PA 19104
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Self-Awareness and Cultural Identity as an Effort to Reduce Bias in Medicine. J Racial Ethn Health Disparities 2017; 5:34-49. [DOI: 10.1007/s40615-017-0340-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 01/09/2017] [Accepted: 01/11/2017] [Indexed: 10/19/2022]
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FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics 2017; 18:19. [PMID: 28249596 PMCID: PMC5333436 DOI: 10.1186/s12910-017-0179-8] [Citation(s) in RCA: 1156] [Impact Index Per Article: 165.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 02/14/2017] [Indexed: 02/06/2023] Open
Abstract
Background Implicit biases involve associations outside conscious awareness that lead to a negative evaluation of a person on the basis of irrelevant characteristics such as race or gender. This review examines the evidence that healthcare professionals display implicit biases towards patients. Methods PubMed, PsychINFO, PsychARTICLE and CINAHL were searched for peer-reviewed articles published between 1st March 2003 and 31st March 2013. Two reviewers assessed the eligibility of the identified papers based on precise content and quality criteria. The references of eligible papers were examined to identify further eligible studies. Results Forty two articles were identified as eligible. Seventeen used an implicit measure (Implicit Association Test in fifteen and subliminal priming in two), to test the biases of healthcare professionals. Twenty five articles employed a between-subjects design, using vignettes to examine the influence of patient characteristics on healthcare professionals’ attitudes, diagnoses, and treatment decisions. The second method was included although it does not isolate implicit attitudes because it is recognised by psychologists who specialise in implicit cognition as a way of detecting the possible presence of implicit bias. Twenty seven studies examined racial/ethnic biases; ten other biases were investigated, including gender, age and weight. Thirty five articles found evidence of implicit bias in healthcare professionals; all the studies that investigated correlations found a significant positive relationship between level of implicit bias and lower quality of care. Discussion The evidence indicates that healthcare professionals exhibit the same levels of implicit bias as the wider population. The interactions between multiple patient characteristics and between healthcare professional and patient characteristics reveal the complexity of the phenomenon of implicit bias and its influence on clinician-patient interaction. The most convincing studies from our review are those that combine the IAT and a method measuring the quality of treatment in the actual world. Correlational evidence indicates that biases are likely to influence diagnosis and treatment decisions and levels of care in some circumstances and need to be further investigated. Our review also indicates that there may sometimes be a gap between the norm of impartiality and the extent to which it is embraced by healthcare professionals for some of the tested characteristics. Conclusions Our findings highlight the need for the healthcare profession to address the role of implicit biases in disparities in healthcare. More research in actual care settings and a greater homogeneity in methods employed to test implicit biases in healthcare is needed.
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Affiliation(s)
- Chloë FitzGerald
- Institute for Ethics, History, and the Humanities, Faculty of Medicine University of Geneva, Genève, Switzerland.
| | - Samia Hurst
- Institute for Ethics, History, and the Humanities, Faculty of Medicine University of Geneva, Genève, Switzerland
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281
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Johnson TJ, Winger DG, Hickey RW, Switzer GE, Miller E, Nguyen MB, Saladino RA, Hausmann LRM. Comparison of Physician Implicit Racial Bias Toward Adults Versus Children. Acad Pediatr 2017; 17:120-126. [PMID: 27620844 PMCID: PMC5337439 DOI: 10.1016/j.acap.2016.08.010] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 08/16/2016] [Accepted: 08/23/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND OBJECTIVES The general population and most physicians have implicit racial bias against black adults. Pediatricians also have implicit bias against black adults, albeit less than other specialties. There is no published research on the implicit racial attitudes of pediatricians or other physicians toward children. Our objectives were to compare implicit racial bias toward adults versus children among resident physicians working in a pediatric emergency department, and to assess whether bias varied by specialty (pediatrics, emergency medicine, or other), gender, race, age, and year of training. METHODS We measured implicit racial bias of residents before a pediatric emergency department shift using the Adult and Child Race Implicit Association Tests (IATs). Generalized linear models compared Adult and Child IAT scores and determined the association of participant demographics with Adult and Child IAT scores. RESULTS Among 91 residents, we found moderate pro-white/anti-black bias on both the Adult (mean = 0.49, standard deviation = 0.34) and Child Race IAT (mean = 0.55, standard deviation = 0.37). There was no significant difference between Adult and Child Race IAT scores (difference = 0.06, P = .15). Implicit bias was not associated with resident demographic characteristics, including specialty. CONCLUSIONS This is the first study demonstrating that resident physicians have implicit racial bias against black children, similar to levels of bias against black adults. Bias in our study did not vary by resident demographic characteristics, including specialty, suggesting that pediatric residents are as susceptible as other physicians to implicit bias. Future studies are needed to explore how physicians' implicit attitudes toward parents and children may impact inequities in pediatric health care.
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Affiliation(s)
- Tiffani J. Johnson
- Division of Pediatric Emergency Medicine, Children's Hospital of Pittsburgh, 4401 Penn Avenue, AOB 2nd Floor Suite 2400, Pittsburgh, PA 15224
- Division of Pediatric Emergency Medicine, PolicyLab, and Center for Perinatal and Pediatric Health Disparities Research, Children's Hospital of Philadelphia; and Department of Pediatrics, University of Pennsylvania School of Medicine, 3535 Market Street Room 1425, Philadelphia, PA 19104
| | - Daniel G. Winger
- Clinical and Translational Science Institute, University of Pittsburgh, Forbes Tower, Suite 7057 Atwood & Sennott Streets, Pittsburgh, PA 15260;
| | - Robert W. Hickey
- Division of Pediatric Emergency Medicine, Children's Hospital of Pittsburgh, 4401 Penn Avenue, AOB 2nd Floor Suite 2400, Pittsburgh, PA 15224;
| | - Galen E. Switzer
- Division of General Internal Medicine, University of Pittsburgh, and Veterans Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Oxford Building, Suite 410, 3501 Forbes Ave., Pittsburgh, PA 15213;
| | - Elizabeth Miller
- Division of Adolescent and Young Adult Medicine, Children's Hospital of Pittsburgh, 3420 Fifth Ave., Pittsburgh, PA 15213;
| | - Margaret B. Nguyen
- Division of Pediatric Emergency Medicine, Children's Hospital of Pittsburgh, 4401 Penn Avenue, AOB 2nd Floor Suite 2400, Pittsburgh, PA 15224;
- Department of Pediatrics, Rady Children's Hospital University of California San Diego, 3020 Children's Way MC 5075, San Diego, CA 92123
| | - Richard A. Saladino
- Division of Pediatric Emergency Medicine, Children's Hospital of Pittsburgh, 4401 Penn Avenue, AOB 2nd Floor Suite 2400, Pittsburgh, PA 15224;
| | - Leslie R. M. Hausmann
- Division of General Internal Medicine, University of Pittsburgh, and Veterans Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, 7180 Highland Drive (151C-H), Pittsburgh, PA 15206;
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282
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Drewniak D, Krones T, Wild V. Do attitudes and behavior of health care professionals exacerbate health care disparities among immigrant and ethnic minority groups? An integrative literature review. Int J Nurs Stud 2017; 70:89-98. [PMID: 28236689 DOI: 10.1016/j.ijnurstu.2017.02.015] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 11/21/2016] [Accepted: 02/10/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Recent investigations of ethnicity related disparities in health care have focused on the contribution of providers' implicit biases. A significant effect on health care outcomes is suggested, but the results are mixed. The purpose of this integrative literature review is to provide an overview and synthesize the current empirical research on the potential influence of health care professionals' attitudes and behaviors towards ethnic minority patients on health care disparities. DESIGN Integrative literature review. DATA SOURCES Four internet-based literature indexes - MedLine, PsychInfo, Sociological Abstracts and Web of Science - were searched for articles published between 1982 and 2012 discussing health care professionals' attitudes or behaviors towards ethnic minority patients. REVIEW METHODS Thematic analysis was used to synthesize the relevant findings. RESULTS We found 47 studies from 12 countries. Six potential barriers to health care for ethnic minorities were identified that may be related to health care professionals' attitudes or behaviors: Biases, stereotypes and prejudices; Language and communication barriers; Cultural misunderstandings; Gate-keeping; Statistical discrimination; Specific challenges of delivering care to undocumented migrants. CONCLUSIONS Data on health care professionals' attitudes or behaviors are both limited and inconsistent. We thus provide reflections on methods, conceptualization, interpretation and the importance of the geographical or socio-political settings of potential studies. More empirical data is needed, especially on health care professionals' attitudes or behaviors towards (irregular) migrant patients.
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Affiliation(s)
- Daniel Drewniak
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Winterthurerstrasse 30, 8006 Zurich, Switzerland.
| | - Tanja Krones
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Winterthurerstrasse 30, 8006 Zurich, Switzerland; Clinical Ethics, University Hospital Zurich, c/o Dermatologische Klinik, Gloriastrasse 31, 8091 Zurich, Switzerland.
| | - Verina Wild
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Winterthurerstrasse 30, 8006 Zurich, Switzerland; Chair of Philosophy IV, Ludwig-Maximilians-University of Munich, Geschwister-Scholl-Platz 1, 80539 Munich, Germany.
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283
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Colón-Emeric CS, Corazzini K, McConnell E, Pan W, Toles M, Hall R, Batchelor-Murphy M, Yap TL, Anderson AL, Burd A, Anderson RA. Study of Individualization and Bias in Nursing Home Fall Prevention Practices. J Am Geriatr Soc 2017; 65:815-821. [PMID: 28186618 DOI: 10.1111/jgs.14675] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVES Little is known about how nursing home staff use resident characteristics to individualize care delivery or whether care is affected by implicit bias. DESIGN Randomized factorial clinical vignette survey. SETTING Sixteen nursing homes in North Carolina. PARTICIPANTS Nursing, rehabilitation, and social services staff (n = 433). MEASUREMENTS Vignettes describing hypothetical residents were generated from a matrix of clinical and demographic characteristics. Resident age, race and gender were suggested by a photo. Participants completed up to four randomly assigned vignettes (n = 1615), rating the likelihood that 12 fall prevention activities would be used for the resident. Fixed and random effects mixed model analysis examined the impact of vignette resident characteristics and staff characteristics on four intervention categories. RESULTS Staff reported a higher likelihood of fall prevention activities in all four categories for residents with a prior fall (0.2-0.5 points higher, 10 point scale, P < 0.05), but other risk factors did not affect scores. There was little evidence of individualization; only dementia increased the reported likelihood of environmental modification (0.3, P < 0.001, 95% CI 0.2-0.5). Individualization did not vary with staff licensure category or clinical experience. Registered nurses consistently reported higher likelihoods of all fall prevention activities than did licensed practical nurses, unlicensed staff and other professional staff (1.0-2.7 points, P < 0.001 to 0.005). There was a small degree of implicit racial bias; staff indicated that environmental modification would be less likely to occur in otherwise identical vignettes including a photo of a black rather than a white resident (-0.2 points, 95% CI -0.3 to -0.1). CONCLUSION Nursing home staff report a standardized approach to fall prevention without individualization. We found a small impact from implicit racial bias that should be further explored.
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Affiliation(s)
- Cathleen S Colón-Emeric
- School of Medicine, Duke University, Durham, North Carolina.,Durham VA Geriatric Research Education and Clinical Center, Durham, North Carolina
| | - Kirsten Corazzini
- School of Medicine, Duke University, Durham, North Carolina.,Durham VA Geriatric Research Education and Clinical Center, Durham, North Carolina.,School of Nursing, Duke University, Durham, North Carolina
| | | | - Wei Pan
- School of Nursing, Duke University, Durham, North Carolina
| | - Mark Toles
- School of Nursing, University of North Carolina, Chapel Hill, North Carolina
| | - Rasheeda Hall
- School of Medicine, Duke University, Durham, North Carolina.,Durham VA Geriatric Research Education and Clinical Center, Durham, North Carolina
| | | | - Tracey L Yap
- School of Nursing, Duke University, Durham, North Carolina
| | | | - Andrew Burd
- School of Nursing, Duke University, Durham, North Carolina
| | - Ruth A Anderson
- School of Nursing, University of North Carolina, Chapel Hill, North Carolina
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284
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Kenison TC, Madu A, Krupat E, Ticona L, Vargas IM, Green AR. Through the Veil of Language: Exploring the Hidden Curriculum for the Care of Patients With Limited English Proficiency. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2017; 92:92-100. [PMID: 27166864 DOI: 10.1097/acm.0000000000001211] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
PURPOSE Patients with limited English proficiency (LEP) experience lower-quality health care and are at higher risk of experiencing adverse events than fluent English speakers. Despite some formal training for health professions students on caring for patients with LEP, the hidden curriculum may have a greater influence on learning. The authors designed this study to characterize the hidden curriculum that medical and nursing students experience regarding the care of patients with LEP. METHOD In 2014, the authors invited students from one medical school and one nursing school, who had completed an interprofessional pilot curriculum on caring for patients with LEP 6 to 10 months earlier, to participate in semistructured interviews about their clinical training experiences with LEP patients. The authors independently coded the interview transcripts, compared them for agreement, and performed content analysis to identify major themes. RESULTS Thirteen students (7 medical and 6 nursing students) participated. Four major themes emerged: role modeling, systems factors, learning environment, and organizational culture. All 13 students described negative role modeling experiences, and most described role modeling that the authors coded as "indifferent." Students felt that the current system and learning environment did not support or emphasize high-quality care for patients with LEP. CONCLUSIONS The hidden curriculum that health professional students experience regarding the care of patients with LEP is influenced by systems limitations and a learning environment and organizational culture that value efficiency over effective communication. Role modeling seems strongly linked to these factors as supervisors struggle with these same challenges.
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Affiliation(s)
- Tiffany C Kenison
- T.C. Kenison is a resident, Department of Medicine, Mount Sinai Hospital, New York, New York. A. Madu is research assistant, Disparities Solutions Center, Massachusetts General Hospital, Boston, Massachusetts. E. Krupat is director, Center for Evaluation, Harvard Medical School, Boston, Massachusetts. L. Ticona is a health policy and management fellow, Massachusetts General Physicians Organization, Massachusetts General Hospital, Boston, Massachusetts. I.M. Vargas is an independent science writer and lead instructor, MOSTEC (MIT Online Science, Technology, and Engineering Community) program, Massachusetts Institute of Technology, Cambridge, Massachusetts. A.R. Green is associate director, Disparities Solutions Center, Massachusetts General Hospital, and Arnold P. Gold Associate Professor of Medicine, Harvard Medical School, Boston, Massachusetts
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285
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Brooks KC, Rougas S, George P. When Race Matters on the Wards: Talking About Racial Health Disparities and Racism in the Clinical Setting. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2016; 12:10523. [PMID: 30984865 PMCID: PMC6440415 DOI: 10.15766/mep_2374-8265.10523] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
INTRODUCTION There is a growing body of literature illustrating the negative impact of racial bias on clinical care. Despite the growing evidence, medical schools have been slow to make necessary curricular changes. Most attempts to educate on racial health disparities focus on transferring knowledge and do not foster the development of skills to understand one's own bias or address bias and racism in the clinical setting. To address this, we developed a small-group, case-based curriculum for rising third-year medical students. METHODS This session was designed to be delivered in concurrently run, 1-hour small-group sessions, with each small group ideally comprising no more than 10 students and one facilitator. The curriculum was integrated into an existing 3-week clerkship preparation course for 122 students during the 2015-2016 academic year. The session materials include a facilitator's guide and three cases for discussion. RESULTS The session was evaluated using a 6-point Likert scale (1 = poor, 6 = exceptional). Students rated this session overall a 4.28 out of 6 (N = 79). Qualitative feedback varied, with the most common theme focusing on the need for more time to discuss this topic. DISCUSSION Though one session before starting clinical clerkships is not enough to maintain the practice of sustained critical thinking regarding bias and racism in clinical medicine, this session is a starting point for curriculum developers looking to use an evidence-based approach to racial bias in clinical care.
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Affiliation(s)
- Katherine C. Brooks
- Recent Graduate, Warren Alpert Medical School of Brown University; Resident Physician in Internal Medicine, Brigham and Women's Hospital
- Corresponding author:
| | - Steven Rougas
- Assistant Professor of Emergency Medicine and Medical Science, Warren Alpert Medical School of Brown University
| | - Paul George
- Assistant Dean of Medical Education, Warren Alpert Medical School of Brown University; Associate Professor of Family Medicine and Medical Science, Warren Alpert Medical School of Brown University
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286
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Mason BS, Ross W, Chambers MC, Grant R, Parks M. Pipeline program recruits and retains women and underrepresented minorities in procedure based specialties: A brief report. Am J Surg 2016; 213:662-665. [PMID: 28302274 DOI: 10.1016/j.amjsurg.2016.11.022] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 10/25/2016] [Accepted: 11/16/2016] [Indexed: 11/28/2022]
Abstract
As the US population continues to grow in racial and ethnic diversity, we also continue to see healthcare disparities across racial lines. Considerable attention has been given to creating a physician workforce that better reflects the population served by healthcare professionals. To address the low numbers of women and underrepresented minorities in procedural based specialties, Nth Dimensions has sought to address and eliminate healthcare disparities through strategic pipeline initiatives. This is a retrospective observational cohort study of 118 medical students from 29 accredited US medical schools, who were awarded a position in the Nth Dimensions Summer Internship program between 2005 and 2012. Overall, 84 NDSI scholars applied and 81 matched into procedure-based specialties; therefore the overall retention rate was 75% and the overall match rate across the eight cohorts was 72.3%. Through intervention-based change, the authors hypothesize that greater numbers in the residency training cohorts can lead to a greater number of physicians with diverse backgrounds and perspectives. Ultimately, this will enhance quality of care for all patients and improve decision making process that influence healthcare systems. SUMMARY Strategic pipeline programs increase successful recruit women and underrepresented minorities to apply and matriculate into procedure based residency programs. This is a retrospective observational cohort study of 118 medical students who completed the Nth Dimensions Summer Internship program between 2005 and 2012. Overall, 84 NDSI scholars applied and 81 matched into procedure-based specialties; therefore the overall retention rate was 75% and the overall match rate across the eight cohorts was 72.3%.
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Affiliation(s)
- Bonnie S Mason
- Nth Dimensions Inc, 22 N Morgan St, Chicago, IL 60607, USA.
| | - William Ross
- Nth Dimensions Inc, 22 N Morgan St, Chicago, IL 60607, USA
| | | | - Richard Grant
- Nth Dimensions Inc, 22 N Morgan St, Chicago, IL 60607, USA
| | - Michael Parks
- Nth Dimensions Inc, 22 N Morgan St, Chicago, IL 60607, USA
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287
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Shin RQ, Smith LC, Welch JC, Ezeofor I. Is Allison More Likely Than Lakisha to Receive a Callback From Counseling Professionals? A Racism Audit Study. COUNSELING PSYCHOLOGIST 2016. [DOI: 10.1177/0011000016668814] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Richard Q. Shin
- Department of Counseling, Higher Education, and Special Education, University of Maryland, College Park, MD, USA
| | - Lance C. Smith
- Graduate Program in Counseling, University of Vermont, Burlington, VT, USA
| | - Jamie C. Welch
- Department of Counseling, Higher Education, and Special Education, University of Maryland, College Park, MD, USA
| | - Ijeoma Ezeofor
- Department of Counseling, Higher Education, and Special Education, University of Maryland, College Park, MD, USA
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288
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Joks R, Bluth MH. Clinical Toxicology and Its Relevance to Asthma and Atopy. Clin Lab Med 2016; 36:795-801. [PMID: 27842794 DOI: 10.1016/j.cll.2016.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Although both the prevalence of asthma and the prescription drug use, notably the opiate analgesic class, epidemics are increasing, there is a complex interplay between both disorders, with both protective and exacerbating factors involved in the effect of opiates on asthma pathogenesis and clinical severity. This review examines the airway effects, both immunologic and neurologic, of opiates, which may interact and result in protection or exacerbation of asthma.
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Affiliation(s)
- Rauno Joks
- SUNY Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY 11203, USA.
| | - Martin H Bluth
- Department of Pathology, Wayne State University School of Medicine, 540 East Canfield, Detroit, MI 48201, USA; Consolidated Laboratory Management Systems, 24555 Southfield Road, Southfield, MI 48075, USA
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289
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Hamel LM, Penner LA, Albrecht TL, Heath E, Gwede CK, Eggly S. Barriers to Clinical Trial Enrollment in Racial and Ethnic Minority Patients With Cancer. Cancer Control 2016; 23:327-337. [PMID: 27842322 PMCID: PMC5131730 DOI: 10.1177/107327481602300404] [Citation(s) in RCA: 288] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Clinical trials that study cancer are essential for testing the safety and effectiveness of promising treatments, but most people with cancer never enroll in a clinical trial - a challenge exemplified in racial and ethnic minorities. Underenrollment of racial and ethnic minorities reduces the generalizability of research findings and represents a disparity in access to high-quality health care. METHODS Using a multilevel model as a framework, potential barriers to trial enrollment of racial and ethnic minorities were identified at system, individual, and interpersonal levels. Exactly how each level directly or indirectly contributes to doctor-patient communication was also reviewed. Selected examples of implemented interventions are included to help address these barriers. We then propose our own evidence-based intervention addressing barriers at the individual and interpersonal levels. RESULTS Barriers to enrolling a diverse population of patients in clinical trials are complex and multilevel. Interventions focused at each level have been relatively successful, but multilevel interventions have the greatest potential for success. CONCLUSION To increase the enrollment of racial and ethnic minorities in clinical trials, future interventions should address barriers at multiple levels.
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Affiliation(s)
- Lauren M Hamel
- Wayne State University, Karmanos Cancer Institute, Department of Oncology, Population Studies Disparities Research Program, Detroit, MI, USA.
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290
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Horner KB, Jones A, Wang L, Winger DG, Marin JR. Variation in advanced imaging for pediatric patients with abdominal pain discharged from the ED. Am J Emerg Med 2016; 34:2320-2325. [PMID: 27613363 DOI: 10.1016/j.ajem.2016.08.041] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 08/19/2016] [Accepted: 08/20/2016] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Pediatric abdominal pain visits to emergency departments (ED) are common. The objectives of this study are to assess variation in imaging (ultrasound ±computed tomography [CT]) and factors associated with isolated CT use. METHODS This was a retrospective cohort study of ED visits for pediatric abdominal pain resulting in discharge from 16 regional EDs from 2007 to 2013. Primary outcome was ultrasound or CT imaging. Secondary outcome was isolated CT use. We used multivariable logistic regression to evaluate patient- and hospital-level covariates associated with imaging. RESULTS Of the 21 152 visits, imaging was performed in 29.7%, and isolated CT in 13.4% of visits. In multivariable analysis, black patients (odds ratio [OR], 0.4; 95% confidence interval [CI], 0.4-0.5) and Medicaid (OR, 0.6; 95% CI, 0.5-0.7) had lower odds of advanced imaging compared with white patients and private insurance, respectively. General EDs were less likely to perform imaging (OR, 0.6; 95% CI, 0.5-0.7) compared with the pediatric ED; however, for visits with imaging, 3.5% of visits to the pediatric ED compared with 76% of those to general EDs included an isolated CT (P<.001). Low pediatric volume (OR, 1.8; 95% CI, 1.5-2.2) and rural (OR,1.8; 95% CI, 1.3-2.5) EDs had higher odds of isolated CT use, compared with higher pediatric volumes and nonrural EDs, respectively. CONCLUSION There are racial and insurance disparities in imaging for pediatric abdominal pain. General EDs are less likely than pediatric EDs to use imaging, but more likely to use isolated CT. Strategies are needed to minimize disparities and improve the use of "ultrasound first."
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Affiliation(s)
- Kimberly B Horner
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA.
| | - Amy Jones
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Li Wang
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA
| | - Daniel G Winger
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA
| | - Jennifer R Marin
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA; Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
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291
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Girod S, Fassiotto M, Grewal D, Ku MC, Sriram N, Nosek BA, Valantine H. Reducing Implicit Gender Leadership Bias in Academic Medicine With an Educational Intervention. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2016; 91:1143-50. [PMID: 26826068 DOI: 10.1097/acm.0000000000001099] [Citation(s) in RCA: 193] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
PURPOSE One challenge academic health centers face is to advance female faculty to leadership positions and retain them there in numbers equal to men, especially given the equal representation of women and men among graduates of medicine and biological sciences over the last 10 years. The purpose of this study is to investigate the explicit and implicit biases favoring men as leaders, among both men and women faculty, and to assess whether these attitudes change following an educational intervention. METHOD The authors used a standardized, 20-minute educational intervention to educate faculty about implicit biases and strategies for overcoming them. Next, they assessed the effect of this intervention. From March 2012 through April 2013, 281 faculty members participated in the intervention across 13 of 18 clinical departments. RESULTS The study assessed faculty members' perceptions of bias as well as their explicit and implicit attitudes toward gender and leadership. Results indicated that the intervention significantly changed all faculty members' perceptions of bias (P < .05 across all eight measures). Although, as expected, explicit biases did not change following the intervention, the intervention did have a small but significant positive effect on the implicit biases surrounding women and leadership of all participants regardless of age or gender (P = .008). CONCLUSIONS These results suggest that providing education on bias and strategies for reducing it can serve as an important step toward reducing gender bias in academic medicine and, ultimately, promoting institutional change, specifically the promoting of women to higher ranks.
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Affiliation(s)
- Sabine Girod
- S. Girod is associate professor, Department of Surgery and, by courtesy, Department of Otolaryngology, Stanford University School of Medicine, Stanford, California. M. Fassiotto is director of programs and research, Office of Faculty Development and Diversity, Stanford University School of Medicine, Stanford, California. D. Grewal is assessment and program evaluation analyst, Office of the Vice Provost for Undergraduate Education, Stanford University, Stanford, California. M.C. Ku is research program manager, Apple Inc., Cupertino, California. N. Sriram is founder of Implisci, Charlottesville, Virginia. B.A. Nosek is professor, Department of Psychology, University of Virginia, and executive director, Center for Open Science, Charlottesville, Virginia. H. Valantine is chief officer for scientific workforce diversity, National Institutes of Health, Bethesda, Maryland. This work was conducted while H. Valantine was at Stanford University, Stanford, California
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Zestcott CA, Blair IV, Stone J. Examining the Presence, Consequences, and Reduction of Implicit Bias in Health Care: A Narrative Review. GROUP PROCESSES & INTERGROUP RELATIONS 2016; 19:528-542. [PMID: 27547105 PMCID: PMC4990077 DOI: 10.1177/1368430216642029] [Citation(s) in RCA: 224] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Recent evidence suggests that one possible cause of disparities in health outcomes for stigmatized groups is the implicit biases held by health care providers. In response, several health care organizations have called for, and developed, new training in implicit bias for their providers. This review examines current evidence on the role that provider implicit bias may play in health disparities, and whether training in implicit bias can effectively reduce the biases that providers exhibit. Directions for future research on the presence and consequences of provider implicit bias, and best practices for training to reduce such bias, will be discussed.
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293
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Marginalization: A Revisitation With Integration of Scholarship on Globalization, Intersectionality, Privilege, Microaggressions, and Implicit Biases. ANS Adv Nurs Sci 2016; 39:200-15. [PMID: 27490876 DOI: 10.1097/ans.0000000000000123] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In 1994, the concept of marginalization was explored in an article in Advances in Nursing Science. This is a revisitation of the concept incorporating new scholarship. This update is founded on feminism, postcolonialism, critical race theory, and discourse deconstruction, all viewpoints that have been explicated in nursing. The purpose of this analysis is to look at new scholarship and concepts useful to applying marginalization in nursing knowledge development from the standpoint of Bourdieu's macro, meso, and micro levels. New scholarship includes globalization, intersectionality, privilege, microaggressions, and implicit bias. Implications for decreasing health disparities through this new scholarship are discussed.
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294
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The influence of patients' immigration background and residence permit status on treatment decisions in health care. Results of a factorial survey among general practitioners in Switzerland. Soc Sci Med 2016; 161:64-73. [PMID: 27258017 DOI: 10.1016/j.socscimed.2016.05.039] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 05/24/2016] [Accepted: 05/25/2016] [Indexed: 11/23/2022]
Abstract
This study examines the influence of patients' immigration background and residence permit status on physicians' willingness to treat patients in due time. A factorial survey was conducted among 352 general practitioners with a background in internal medicine in a German-speaking region in Switzerland. Participants expressed their self-rating (SR) as well as the expected colleague-rating (CR) to provide immediate treatment to 12 fictive vignette patients. The effects of the vignette variables were analysed using random-effects models. The results show that SR as well as CR was not only influenced by the medical condition or the physicians' time pressure, but also by social factors such as the ethnicity and migration history, the residence permit status, and the economic condition of the patients. Our findings can be useful for the development of adequate, practically relevant teaching and training materials with the ultimate aim to reduce unjustified discrimination or social rationing in health care.
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295
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African Americans Have Better Outcomes for Five Common Gastrointestinal Diagnoses in Hospitals With More Racially Diverse Patients. Am J Gastroenterol 2016; 111:649-57. [PMID: 27002802 DOI: 10.1038/ajg.2016.64] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 02/01/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES We sought to characterize the relationship between hospital inpatient racial diversity and outcomes for African-American patients including rates of major complications or mortality during hospitalization for five common gastrointestinal diagnoses. METHODS Using the 2012 National Inpatient Sample database, hospital inpatient racial diversity was defined as the percentage of African-American patients discharged from each hospital. Logistic regression was used to predict major complication rates or death, long length of stay, and high total charges. Control variables included age, gender, payer type, patient location, area-associated income quartile, hospital characteristics including size, urban vs. rural, teaching vs. nonteaching, region, and the interaction of the percentage of African Americans with patient race. RESULTS There were 848,395 discharges across 3,392 hospitals. The patient population was on average 27% minority (s.d.±21%) with African Americans accounting for 14% of all patients. Overall, African-American patients had higher rates of major complications or death relative to white patients (adjusted odds ratio (aOR) 1.19; 95% confidence interval (CI) 1.16-1.23). However, when treated in hospitals with higher patient racial diversity, African-American patients experienced significantly lower rates of major complications or mortality (aOR 0.80; 95% CI 0.74-0.86). CONCLUSIONS African Americans have better outcomes for five common gastrointestinal diagnoses when treated in hospitals with higher inpatient racial diversity. This has major ramifications on total hospital charges.
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297
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Augusto LM. Lost in dissociation: The main paradigms in unconscious cognition. Conscious Cogn 2016; 42:293-310. [PMID: 27107894 DOI: 10.1016/j.concog.2016.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 03/05/2016] [Accepted: 04/10/2016] [Indexed: 10/21/2022]
Abstract
Contemporary studies in unconscious cognition are essentially founded on dissociation, i.e., on how it dissociates with respect to conscious mental processes and representations. This is claimed to be in so many and diverse ways that one is often lost in dissociation. In order to reduce this state of confusion we here carry out two major tasks: based on the central distinction between cognitive processes and representations, we identify and isolate the main dissociation paradigms; we then critically analyze their key tenets and reported findings.
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Affiliation(s)
- Luis M Augusto
- University of Barcelona (Visiting researcher), Barcelona, Spain.
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298
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Carlsson R, Agerström J. A closer look at the discrimination outcomes in the IAT literature. Scand J Psychol 2016; 57:278-87. [PMID: 27109866 DOI: 10.1111/sjop.12288] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 02/28/2016] [Indexed: 11/27/2022]
Abstract
To what extent the IAT (Implicit Association Test, Greenwald et al., 1998) predicts racial and ethnic discrimination is a heavily debated issue. The latest meta-analysis by Oswald et al. (2013) suggests a very weak association. In the present meta-analysis, we switched the focus from the predictor to the criterion, by taking a closer look at the discrimination outcomes. We discovered that many of these outcomes were not actually operationalizations of discrimination, but rather of other related, but distinct, concepts, such as brain activity and voting preferences. When we meta-analyzed the main effects of discrimination among the remaining discrimination outcomes, the overall effect was close to zero and highly inconsistent across studies. Taken together, it is doubtful whether the amalgamation of these outcomes is relevant criteria for assessing the IAT's predictive validity of discrimination. Accordingly, there is also little evidence that the IAT can meaningfully predict discrimination, and we thus strongly caution against any practical applications of the IAT that rest on this assumption. However, provided that the application is thoroughly informed by the current state of the literature, we believe the IAT can still be a useful tool for researchers, educators, managers, and students who are interested in attitudes, prejudices, stereotypes, and discrimination.
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Affiliation(s)
| | - Jens Agerström
- Department of Psychology, Linnaeus University, Kalmar, Sweden
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299
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McSweeney JC, Rosenfeld AG, Abel WM, Braun LT, Burke LE, Daugherty SL, Fletcher GF, Gulati M, Mehta LS, Pettey C, Reckelhoff JF. Preventing and Experiencing Ischemic Heart Disease as a Woman: State of the Science: A Scientific Statement From the American Heart Association. Circulation 2016; 133:1302-31. [PMID: 26927362 PMCID: PMC5154387 DOI: 10.1161/cir.0000000000000381] [Citation(s) in RCA: 176] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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300
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Johnson TJ, Hickey RW, Switzer GE, Miller E, Winger DG, Nguyen M, Saladino RA, Hausmann LRM. The Impact of Cognitive Stressors in the Emergency Department on Physician Implicit Racial Bias. Acad Emerg Med 2016; 23:297-305. [PMID: 26763939 DOI: 10.1111/acem.12901] [Citation(s) in RCA: 108] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 10/09/2015] [Accepted: 10/17/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The emergency department (ED) is characterized by stressors (e.g., fatigue, stress, time pressure, and complex decision-making) that can pose challenges to delivering high-quality, equitable care. Although it has been suggested that characteristics of the ED may exacerbate reliance on cognitive heuristics, no research has directly investigated whether stressors in the ED impact physician racial bias, a common heuristic. We seek to determine if physicians have different levels of implicit racial bias post-ED shift versus preshift and to examine associations between demographics and cognitive stressors with bias. METHODS This repeated-measures study of resident physicians in a pediatric ED used electronic pre- and postshift assessments of implicit racial bias, demographics, and cognitive stressors. Implicit bias was measured using the Race Implicit Association Test (IAT). Linear regression models compared differences in IAT scores pre- to postshift and determined associations between participant demographics and cognitive stressors with postshift IAT and pre- to postshift difference scores. RESULTS Participants (n = 91) displayed moderate prowhite/antiblack bias on preshift (mean ± SD = 0.50 ± 0.34, d = 1.48) and postshift (mean ± SD = 0.55 ± 0.39, d = 1.40) IAT scores. Overall, IAT scores did not differ preshift to postshift (mean increase = 0.05, 95% CI = -0.02 to 0.14, d = 0.13). Subanalyses revealed increased pre- to postshift bias among participants working when the ED was more overcrowded (mean increase = 0.09, 95% CI = 0.01 to 0.17, d = 0.24) and among those caring for >10 patients (mean increase = 0.17, 95% CI = 0.05 to 0.27, d = 0.47). Residents' demographics (including specialty), fatigue, busyness, stressfulness, and number of shifts were not associated with postshift IAT or difference scores. In multivariable models, ED overcrowding was associated with greater postshift bias (coefficient = 0.11 per 1 unit of NEDOCS score, SE = 0.05, 95% CI = 0.00 to 0.21). CONCLUSIONS While resident implicit bias remained stable overall preshift to postshift, cognitive stressors (overcrowding and patient load) were associated with increased implicit bias. Physicians in the ED should be aware of how cognitive stressors may exacerbate implicit racial bias.
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Affiliation(s)
- Tiffani J. Johnson
- Division of Pediatric Emergency Medicine; PolicyLab, and Center for Perinatal and Pediatric Health Disparities Research; Children's Hospital of Philadelphia, and the Department of Pediatrics; University of Pennsylvania School of Medicine; Philadelphia PA
| | - Robert W. Hickey
- Division of Pediatric Emergency Medicine; Department of Pediatrics; University of Pittsburgh; Pittsburgh PA
| | - Galen E. Switzer
- Division of General Internal Medicine; Department of Medicine; University of Pittsburgh; Pittsburgh PA
- Veterans Affairs Pittsburgh Healthcare System; Center for Health Equity Research and Promotion; Pittsburgh PA
| | - Elizabeth Miller
- Division of Adolescent and Young Adult Medicine; Department of Pediatrics; University of Pittsburgh; Pittsburgh PA
| | - Daniel G. Winger
- Clinical and Translational Science Institute; University of Pittsburgh; Pittsburgh PA
| | - Margaret Nguyen
- Department of Emergency Medicine; Rady Children's Hospital San Diego; San Diego CA
| | - Richard A. Saladino
- Division of Pediatric Emergency Medicine; Department of Pediatrics; University of Pittsburgh; Pittsburgh PA
| | - Leslie R. M. Hausmann
- Division of General Internal Medicine; Department of Medicine; University of Pittsburgh; Pittsburgh PA
- Veterans Affairs Pittsburgh Healthcare System; Center for Health Equity Research and Promotion; Pittsburgh PA
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