Implicit Bias Education and Emergency Medicine Training: Step One? Awareness

Implicit Bias and Health Disparities Education in the Neonatal Intensive Care Unit

OBJECTIVE

 This study aimed to characterize implicit bias (IB) and health disparities (HD) education in neonatal-perinatal medicine (NPM), including current educational opportunities, resources, and barriers.

STUDY DESIGN

 A national web-based survey was sent to NPM fellows, neonatologists, and frontline providers after iterative review by education experts from the National Neonatology Curriculum Committee. Quantitative data were analyzed with chi-square and Fisher's exact tests. Qualitative data were evaluated using thematic analysis.

RESULTS

 Of the 452 NPM survey respondents, most desired additional IB (76%) and HD (83%) education. A greater proportion of neonatologists than fellows received IB (83 vs. 57%) and HD (87 vs. 74%) education. Only 41% of neonatologists reported that their institution requires IB training. A greater proportion of fellows than neonatologists expressed dissatisfaction with the current approaches for IB (51 vs. 25%, p < 0.001) and HD (43 vs. 25%, p = 0.015) education. The leading drivers of dissatisfaction included insufficient time spent on the topics, lack of specificity to NPM, inadequate curricular scope or depth, and lack of local educator expertise. A minority of faculty who were tasked to educate others have received specific educator training on IB (21%) and HD (16%). Thematic analysis of survey free-text responses identified three main themes on the facilitators and barriers to successful IB and HD education: individual, environmental, and curricular design variables.

CONCLUSION

 NPM trainees and neonatologists desire tailored, active, and expert-guided IB and HD education. Identified barriers are important to address in developing an effective IB/HD curriculum for the NPM community.

KEY POINTS

· There is a gap between the current delivery of IB/HD education and the needs of the NPM community.. · NPM trainees and neonatologists desire tailored, active, and expert-guided IB and HD education.. · A successful curriculum should be widely accessible, NPM-specific, and include facilitator training..

The nature and validity of implicit bias training for health care providers and trainees: A systematic review

The number of health care educational institutions/organizations adopting implicit bias training is growing. Our systematic review of 77 studies (published 1 January 2003 through 21 September 2022) investigated how implicit bias training in health care is designed/delivered and whether gaps in knowledge translation compromised the reliability and validity of the training. The primary training target was race/ethnicity (49.3%); trainings commonly lack specificity on addressing implicit prejudice or stereotyping (67.5%). They involved a combination of hands-on and didactic approaches, lasting an average of 343.15 min, often delivered in a single day (53.2%). Trainings also exhibit translational gaps, diverging from current literature (10 to 67.5%), and lack internal (99.9%), face (93.5%), and external (100%) validity. Implicit bias trainings in health care are characterized by bias in methodological quality and translational gaps, potentially compromising their impacts.

Public Perceptions of Treating Opioid Use Disorder With Deep Brain Stimulation: Comment Analysis Study

BACKGROUND

The number of opioid-related deaths in the United States has more than tripled over the past 7 years, with a steep increase beginning at the same time as the COVID-19 pandemic. There is an urgent need for novel treatment options that can help alleviate the individual and social effects of refractory opioid use disorder (OUD). Deep brain stimulation (DBS), an intervention that involves implanting electrodes in the brain to deliver electrical impulses, is one potential treatment. Currently in clinical trials for many psychiatric conditions, including OUD, DBS's use for psychiatric indications is not without controversy. Several studies have examined ethical issues raised by using DBS to counter treatment-resistant depression, obsessive-compulsive disorder, and eating disorders. In contrast, there has been limited literature regarding the use of DBS for OUD.

OBJECTIVE

This study aims to gain empirical neuroethical insights into public perceptions regarding the use of DBS for OUD, specifically via the analysis of web-based comments on news media stories about the topic.

METHODS

Qualitative thematic content analysis was performed on 2 Washington Post newspaper stories that described a case of DBS being used to treat OUD. A total of 292 comments were included in the analysis, 146 comments from each story, to identify predominant themes raised by commenters.

RESULTS

Predominant themes raised by commenters across the 2 samples included the hopes and expectations with treatment outcomes, whether addiction is a mental health disorder, and issues related to resource allocation. Controversial comments regarding DBS as a treatment method for OUD seemingly decreased when comparing the first printed newspaper story to the second. In comparison, the number of comments relating to therapeutic need increased over time.

CONCLUSIONS

The general public's perspectives on DBS as a treatment method for OUD elucidated themes via this qualitative thematic content analysis that include overarching sociopolitical issues, positions on the use of technology, and technological and scientific issues. A better understanding of the public perceptions around the use of DBS for OUD can help address misinformation and misperceptions about the use of DBS for OUD, and identify similarities and differences regarding ethical concerns when DBS is used specifically for OUD compared to other psychiatric disorders.

Delayed diagnosis of new onset pediatric diabetes leading to diabetic ketoacidosis: a retrospective cohort study

OBJECTIVES

Patients with a delayed diagnosis of diabetes are more likely to present in diabetic ketoacidosis (DKA). The objective of this study was to assess the prevalence, risk factors, and consequences of missed pediatric diabetes diagnoses in emergency departments (EDs) potentially leading to DKA.

METHODS

Cases of children under 19 years old with a first-time diagnosis of diabetes mellitus presenting to EDs in DKA were drawn from the Healthcare Cost and Utilization Project database. A total of 11,716 cases were included. A delayed diagnosis of diabetes leading to DKA was defined by an ED discharge in the 14 days prior to the DKA diagnosis. The delayed diagnosis cases were analyzed using multivariate analysis to identify risk factors associated with delay, with the primary exposure being child opportunity index (COI) and secondary exposure being race/ethnicity. Rates of complications were compared across groups.

RESULTS

Delayed diagnosis of new onset diabetes leading to DKA occurred in 2.9 %. Delayed diagnosis was associated with COI, with 4.5 , 3.5, 1.9, and 1.5 % occurring by increasing COI quartile (p<0.001). Delays were also associated with younger age and non-Hispanic Black race. Patients with a delayed diagnosis were more likely to experience complications (4.4 vs. 2.2 %, p=0.01) including mechanical ventilation, as well as more frequent intensive care unit admissions and longer length of stays.

CONCLUSIONS

Among children with new-onset DKA, 2.9 % had a delayed diagnosis. Delays were associated with complications. Children living in areas with lower child opportunity and non-Hispanic Black children were at higher risk of delays.

Investigating Unconscious Race Bias and Bias Awareness Among Vascular Surgeons

Background

Implicit bias can influence behavior and decision-making. In clinical settings, implicit bias may influence treatment decisions and contribute to health disparities. Given documented Black-White disparities in vascular care, the purpose of this study was to examine the prevalence and degree of unconscious bias and awareness of bias among vascular surgeons treating peripheral artery disease (PAD).

Methods

The sampling frame included all vascular surgeons who participate in the Vascular Quality Initiative (VQI). Participants completed a survey which included demographic questions, the race implicit association test (IAT) to measure magnitude of unconscious bias, and six bias awareness questions to measure conscious bias. The magnitude of unconscious bias was no preference; or slight, moderate, or strong in the direction of pro-White or pro-Black. Data from participants were weighted to account for nonresponse bias and known differences in the characteristics of surgeons who chose to participate compared to the full registry. We stratified unconscious and conscious findings by physician race/ethnicity, physician sex, and years of experience. Finally, we examined the relationship between unconscious and conscious bias.

Results

There were 2,512 surgeons in the VQI registry, 304 of whom completed the survey, including getting IAT results. Most participants (71.6%) showed a pro-White bias with 73.0% of this group in the moderate and strong categories. While 77.5% of respondents showed conscious awareness of bias, of those whose conscious results showed lack of awareness, 67.8% had moderate or strong bias, compared to 55.7% for those with awareness. Bias magnitude varied based on physician race/ethnicity and years of experience. Women were more likely than men to report awareness of biases and potential impact of bias on decision-making.

Conclusions

Most people have some level of unconscious bias, developed from early life reinforcements, social stereotypes, and learned experiences. Regarding health disparities, however, these are important findings in a profession that takes care of patients with PAD due to heavy burden of comorbid conditions and high proportion of individuals from structurally vulnerable groups. Given the lack of association between unconscious and conscious awareness of biases, awareness may be an important first step in mitigation to minimize racial disparities in healthcare.

Health Care for Youth With Neurodevelopmental Disabilities: A Consensus Statement

Individuals with a neurodevelopmental disability (NDD) face significant health care barriers, disparities in health outcomes, and high rates of foregone and adverse health care experiences. The Supporting Access for Everyone (SAFE) Initiative was developed to establish principles of health care to improve equity for youth with NDDs through an evidence-informed and consensus-derived process. With the Developmental Behavioral Pediatric Research Network, the SAFE cochairs convened a consensus panel composed of diverse professionals, caregivers, and adults with NDDs who contributed their varied expertise related to SAFE care delivery. A 2-day public forum (attended by consensus panel members) was convened where professionals, community advocates, and adults with NDDs and/or caregivers of individuals with NDDs presented research, clinical strategies, and personal experiences. After this, a 2-day consensus conference was held. Using nominal group technique, the panel derived a consensus statement (CS) on SAFE care, an NDD Health Care Bill of Rights, and Transition Considerations. Ten CSs across 5 topical domains were established: (1) training, (2) communication, (3) access and planning, (4) diversity, equity, inclusion, belonging, and anti-ableism, and (5) policy and structural change. Relevant and representative citations were added when available to support the derived statements. The final CS was approved by all consensus panel members and the Developmental Behavioral Pediatric Research Network steering committee. At the heart of this CS is an affirmation that all people are entitled to health care that is accessible, humane, and effective.

Piloting racial bias training for hospital emergency department providers treating patients with opioid use disorder

Racial disparities in opioid overdose have increased in recent years. Several studies have linked these disparities to health care providers' inequitable delivery of opioid use disorder (OUD) services. In response, health care policymakers and systems have designed new programs to improve equitable OUD care delivery. Racial bias training has been 1 commonly utilized program. Racial bias training educates providers about the existence of racial disparities in the treatment of people who use drugs and the role of implicit bias. Our study evaluates a pilot racial bias training delivered to 25 hospital emergency providers treating patients with OUDs in 2 hospitals in Detroit, Michigan. We conducted a 3-part survey, including a baseline assessment, post-training assessment, and a 2-month follow-up to evaluate the acceptability and feasibility of scaling the racial bias training to larger audiences. We also investigate preliminary data on changes in self-awareness of implicit bias, knowledge of training content, and equity in care delivery to patients with OUD. Using qualitative survey response data, we found that training participants were satisfied with the content and quality of the training and especially valued the small-group discussions, motivational interviewing, and historical context.

Trends and Disparities in Curative-Intent Treatment for Early-Stage Non-Small Cell Lung Cancer: A Population-Based Analysis of Surgery and SBRT

BACKGROUND

Despite the increasing adoption of stereotactic body radiotherapy (SBRT) as a recommended alternative for early-stage non-small cell lung cancer (NSCLC), population-based research on racial/ethnic disparities in curative-intent treatment accounting for SBRT remains limited. This study investigated trends and disparities in receiving curative-intent surgery and/or SBRT in a diverse, retrospective cohort.

METHODS

Early-stage NSCLC cases (2005-2017) from the Florida cancer registry were linked to individual-level statewide discharge data containing comorbidities and specific treatment information. Joinpoint regression assessed trends in treatment receipt. Multivariable logistic regression examined associations between race/ethnicity and treatment type.

RESULTS

Among 64,999 patients with early-stage NSCLC, 71.6% received curative-intent treatment (surgery and/or SBRT): 73.1%, 72.4%, and 60.3% among Hispanic, White, and Black patients, respectively (P < 0.01). SBRT use increased steeply from 2005 to 2007 and then by 7.9% annually from 2007 to 2017 (P < 0.01); curative-intent surgery remained stable from 2005 to 2014 before declining by 6.2% annually during 2014-2017 (P = 0.04). The Black-White disparity in receipt of curative-intent treatment was significant [ORadj, 0.65; 95% confidence interval (CI), 0.60-0.71]. Patients with Charlson comorbidity index (CCI)≥3 had 36% (ORadj, 0.64; 95% CI, 0.60-0.69) lower odds of receiving curative-intent surgery and no significant difference for SBRT (ORadj, 1.06; 95% CI, 0.93-1.20) compared with CCI = 0.

CONCLUSIONS

Racial disparities in receiving curative-intent treatment for early-stage NSCLC persist despite the availability of SBRT, suggesting the full potential of curative-intent treatment for early-stage NSCLC remains unachieved.

IMPACT

Addressing disparities in early-stage NSCLC requires addressing differential treatment patterns and enhancing accessibility to treatments like underutilized SBRT, particularly for high-comorbidity populations such as Black patients.

"I don't want to be the squeaky wheel": Addressing bias as a leader in emergency medicine

BACKGROUND

Implicit bias poses a barrier to inclusivity in the health care workforce and is detrimental to patient care. While previous studies have investigated knowledge and training gaps related to implicit bias, emergency medicine (EM) leaders' self-awareness and perspectives on bias have not been studied. Using art to prompt reflections on implicit bias, this qualitative study explores (1) the attitudes of leaders in EM toward implicit bias and (2) individual or structural barriers to navigating and addressing bias in the workplace.

METHODS

Investigators facilitated an hour-long workshop in May 2022 for those with leadership positions in the Society for Academic Emergency Medicine (SAEM), a leading national EM organization, including 62 attending physicians, eight residents/fellows, and four medical students. The workshop utilized arts-based methods to generate a psychologically supportive space to lead conversations around implicit bias in EM. The session included time for individual reflection, where participants used an electronic platform to respond anonymously to questions regarding susceptibility, fears, barriers, and experiences surrounding bias. Two independent coders compiled, coded, and reviewed the responses using an exploratory constructivist approach.

RESULTS

A total of 125 responses were analyzed. Four major themes emerged: (1) acceptance that bias exists; (2) individual barriers, including fear of negative reactions, often due to power dynamics between respondents and other members of the ED; (3) institutional barriers, such as insufficient funding and unprotected time committed to addressing bias; and (4) ambiguity about defining and prioritizing bias.

CONCLUSIONS

This qualitative analysis of reflections from an arts-based workshop highlights perceived fears and barriers that may impact EM physicians' motivation and comfort in addressing bias. These results may help guide interventions to address individual and structural barriers to mitigating bias in the workplace.

Racial and Ethnic Disparities in Otolaryngology Applicants and Residents: Recruiting a Diverse Workforce

OBJECTIVE

The purpose of this study is to examine the racial and ethnic representation of otolaryngology applicants and residents and determine if there have been any improvements in recruiting a diverse workforce over the past several years.

METHODS

A retrospective study was conducted on self-reported race and ethnicity data of otolaryngology applicants to United States residency programs from 2016 to 2022 from the Association of American Medical Colleges (AAMC) and residents from 2011 to 2022 from the Accreditation Council for Graduate Medical Education (ACGME). The changes in proportions of applicants and residents by race and ethnicity separately was compared as well as the proportion of applicants to residents. Descriptive analyses and chi-square tests were used to compare proportions of groups by race and ethnicity.

RESULTS

There was no statistically significant difference in the proportion of applicants by race or ethnicity from 2016-2017 to 2021-2022. There was a decrease in the proportion of White residents from 58.1% to 54.5% from 2011-2012 to 2018-2019. There were higher proportions of White residents than applicants and lower proportions of Black residents than applicants in the two cycles analyzed. In the most recent cycle analyzed, the proportion of Hispanic or Latino residents was higher than the proportion of Hispanic or Latino applicants.

CONCLUSION

While there may be improvements to increase representation of otolaryngology applicants and residents, there continues to be inequalities and a lack of diversity. Further initiatives are needed to ensure diversity in the field improves moving forward.

Is There an Implicit Racial Bias in the Case Order of Elective Total Joint Arthroplasty?

INTRODUCTION

Identifying ways to improve equitable access to healthcare is of the utmost important. In this study, we analyzed whether patient race was negatively associated with surgical start times for total joint arthroplasties (TJA).

METHODS

The surgical case order and start times of all primary TJAs performed at a large academic medical center between May 2014 and May 2018 were retrospectively reviewed. Patients were included if > 21, had a documented self-reported race, and were operated on by an arthroplasty fellowship-trained surgeon. Operations were categorized as first-start, early (7:00 AM-11:00 AM), mid-day (11:00 AM-3:00 PM), or late (after 3:00 PM). Multivariable logistic regression (MLR) was performed, and odds ratios (OR) were calculated.

RESULTS

This study identified 1663 TJAs-871 total knee (TKA) and 792 total hip arthroplasties (THA) who met inclusion criteria. Overall, there was no association between race and surgical start time. Upon sub-analysis by surgical type, this held true for TKA patients, but self-identifying Hispanic and non-Hispanic Black patients undergoing THA were more likely to have later surgical start times (ORs: 2.08 and 1.88; p < 0.05).

DISCUSSION

Although there was no association between race and overall TJA surgical start times, patients with marginalized racial and ethnic identities were more likely to undergo elective THA later in the surgical day. Surgeons should be aware of potential implicit bias when determining case order to potentially prevent adverse outcomes due to staff fatigue or lack of proper resources later in the day.

Operationalizing inclusion: moving from an elusive goal to strategic action

To mitigate the structural and institutional biases that contribute to inequities in health, we need a diverse cadre of individuals to feel included and advance within our field in order to bring a multicultural set of perspectives to the studies we conduct, the science we generate, the health and academic systems we design, and the medical and scientific knowledge we impart. There has been increasing focus on diversity, inclusion, and equity in recent years; however, often these terms are presented without adequate precision and, therefore, the inability to effectively operationalize inclusion and achieve diversity within organizations. This narrative review details several key studies, with the primary objective of presenting a roadmap to guide defining, measuring, and operationalizing inclusion within work and learning environments.

Peer-mentorship and first-year inclusion: building belonging in higher education

BACKGROUND

An inclusive academic environment is pivotal to ensure student well-being and a strong sense of belonging and authenticity. Specific attention for an inclusive learning environment is particularly important during a student's transition to higher education. At Utrecht University's Medical School, explorative interviews with students from minority groups indicated they did not always feel included during the orientation programme of their academic education. We, therefore, developed a bias awareness training with theoretical and practical components on diversity and inclusion for peer-mentors who are assigned to each first-year student at the start of university.

METHODS

At the end of the orientation programme, we investigated the effectiveness of the training for two consecutive years using two measurements. Firstly, we investigated the behavioural changes in the peer-mentors through a (self-reporting) questionnaire. Additionally, we measured the perceived inclusion of the first-year students, divided into belonging and authenticity, using a validated questionnaire.

RESULTS

Our results show that peer-mentors found the training useful and indicated it enabled them to create an inclusive atmosphere. Overall, students experienced a high level of inclusion during the orientation programme. After the first year, the bias training was adjusted based on the evaluations. This had a positive effect, as mentors felt they were significantly more able to provide an inclusive orientation in the second year of this study. In line with this, students experienced an increased level of authenticity specifically due to the peer-mentor in the second year as compared to the first.

CONCLUSIONS

We conclude that training peer-mentors is an effective way to increase awareness and to ensure an inclusive atmosphere during the start of higher education.

Medical Student Perception of Strabismus in Race Implicit Association Test

PURPOSE

To determine whether the appearance of strabismus is noted in a race implicit association test by medical students.

METHODS

Medical students participated in a survey evaluating for the appearance of strabismus in photographs from a commonly used race implicit association test. Analysis was performed to determine whether strabismus was perceived equally between both groups tested.

RESULTS

Photographs of six individuals of African descent were perceived as having strabismus more frequently (62%) than photographs of individuals of European descent (31%; odds ratio: 3.85; 95% CI: 3.34 to 4.44; P < .0001). Participants who identified as Black or African American similarly perceived strabismus more frequently in individuals of African descent (58%) than those of European descent (24%; odds ratio: 4.36; 95% CI: 2.13 to 8.96; P < .0001).

CONCLUSIONS

Photographs used in a common race implicit association test appear to differ not only in ethnicity but also in extraocular alignment. Because extraocular alignment is a known cause of negative prejudice, results of this particular implicit association test should be interpreted with caution. [J Pediatr Ophthalmol Strabismus. 2023;60(5):372-376.].

Time to act: A rubric-based approach for institutionalizing justice, equity, diversity, and inclusion

Attacks on minoritized communities and increasing awareness of the societal causes of health disparities have combined to highlight deep systemic inequities. In response, academic health centers have prioritized justice, equity, diversity, and inclusion (JEDI) in their strategic goals. To have a sustained impact, JEDI efforts cannot be siloed; rather, they must be woven into the fabric of our work and systematically assessed to promote meaningful outcomes and accountability. To this end, the University of Pittsburgh's Institute for Clinical Research Education assembled a task force to create and apply a rubric to identify short and long-term JEDI goals, assess the current state of JEDI at our Institute, and make recommendations for immediate action. To ensure deep buy-in, we gathered input from diverse members of our academic community, who served on targeted subcommittees. We then applied a three-step process to ensure rapid forward progress. We emerged with concrete actions for priority focus and a plan for ongoing assessment of JEDI institutionalization. We believe our process and rubric offer a scalable and adaptable model for other institutions and departments to follow as we work together across academic medical institutions to put our justice, equity, diversity, and inclusion goals into meaningful action.

Racial and Ethnic Bias in Medical School Clinical Grading: A Review

OBJECTIVE

Improving diversity in healthcare is a widely recognized national goal. The diversity of medical student matriculants has increased, yet this trend is not seen in the composition of competitive residency programs. In this review, we examine racial and ethnic disparities in medical student grading during clinical years and explore the consequences of how this may exclude minority students from accessing competitive residency positions.

DESIGN

Following PRISMA guidelines, we searched PubMed, Embase, Scopus, and ERIC databases using variations of the terms "race," "ethnicity," "clerkship," "rotation," "grade," "evaluation", or "shelf exam." Of 391 references found using the criteria, 29 were related to clinical grading and race/ethnicity and included in the review. The GRADE criteria were used to determine the quality of evidence.

SETTING

Johns Hopkins School of Medicine, Baltimore MD.

RESULTS

Five studies examining a total of 107,687 students from up to 113 different schools found racial minority students receive significantly fewer Honors grades in core clerkships compared to White students. Three studies examining 94,814 medical student evaluations from up to 130 different schools found significant disparities in the wording of written clerkship evaluations based on race and/or ethnicity.

CONCLUSIONS

A large body of evidence suggests the presence of racial bias in subjective clinical grading and written clerkship evaluations of medical students. Grading disparities can disadvantage minority students when applying to competitive residency programs and may contribute to a lack of diversity in these fields. As low minority representation has a negative impact on patient care and research advancement, strategies to resolve this issue must be further explored.

Beyond diversity and inclusion: Developing a research agenda for anti-racism in emergency medicine education

Background

Addressing racism in emergency medicine education is vital for providing optimal training and assessment of physicians in the specialty, developing physicians with the skills necessary to advocate for their patients, and recruiting and retaining a diverse group of physicians. To form a prioritized research agenda, the Society of Academic Emergency Medicine (SAEM) conducted a consensus conference at the annual meeting in May 2022 on addressing racism in emergency medicine, which included a subgroup on education.

Methods

The education workgroup worked on summarizing the current literature on addressing racism in emergency medicine education, identifying critical knowledge gaps, and creating a consensus-driven research agenda for addressing racism in emergency medicine education. We used a nominal group technique and modified Delphi to develop priority questions for research. We then distributed a pre-conference survey to conference registrants to rate priority areas for research. During the consensus conference, group leaders provided an overview and background describing the rationale for the preliminary research question list. Attendees were then involved in discussions to help modify and develop research questions.

Results

Nineteen questions were initially selected by the education workgroup as potential areas for research. The education workgroup's next round of consensus building resulted in a consensus of ten questions to be included in the pre-conference survey. No questions in the pre-conference survey reached consensus. After robust discussion and voting by workgroup members and attendees at the consensus conference, six questions were determined to be priority research areas.

Conclusions

We believe recognizing and addressing racism in emergency medicine education is imperative. Critical gaps in curriculum design, assessment, bias training, allyship, and the learning environment negatively impact training programs. These gaps must be prioritized for research as they can have adverse effects on recruitment, the ability to promote a safe learning environment, patient care, and patient outcomes.

Implicit bias instruction across disciplines related to the social determinants of health: a scoping review

One criticism of published curricula addressing implicit bias is that few achieve skill development in implicit bias recognition and management (IBRM). To inform the development of skills-based curricula addressing IBRM, we conducted a scoping review of the literature inquiring, "What interventions exist focused on IBRM in professions related to social determinants of health: education, law, social work, and the health professions inclusive of nursing, allied health professions, and medicine?"Authors searched eight databases for articles published from 2000 to 2020. Included studies: (1) described interventions related to implicit bias; and (2) addressed knowledge, attitude and/or skills as outcomes. Excluded were interventions solely focused on reducing/neutralizing implicit bias. Article review for inclusion and data charting occurred independently and in duplicate. Investigators compared characteristics across studies; data charting focused on educational and assessment strategies. Fifty-one full-text articles for data charting and synthesis, with more than 6568 learners, were selected. Educational strategies included provocative/engagement triggers, the Implicit Association Test, reflection and discussion, and various active learning strategies. Most assessments were self-report, with fewer objective measures. Eighteen funded studies utilized federal, foundation, institutional, and private sources. This review adds to the literature by providing tangible examples of curricula to complement existing frameworks, and identifying opportunities for further research in innovative skills-based instruction, learner assessment, and development and validation of outcome metrics. Continued research addressing IBRM would enable learners to develop and practice skills to recognize and manage their implicit biases during clinical encounters, thereby advancing the goal of improved, equitable patient outcomes.

Toward Improving Patient Equity in a Pediatric Emergency Department: A Framework for Implementation

Disparities in health care delivery and health outcomes for patients in the emergency department (ED) by race, ethnicity, and language for care (REaL) are common and well documented. Addressing inequities from structural racism, implicit bias, and language barriers can be challenging, and there is a lack of data on effective interventions. We describe the implementation of a multifaceted equity improvement strategy in a pediatric ED using Kotter's model for change as a framework to identify the key drivers. The main elements included a data dashboard with quality metrics stratified by patient self-reported REaL to visualize disparities, a staff workshop on implicit bias and microaggressions, and several clinical and operational tools that highlight equity. Our next steps include refining and repeating interventions and tracking important patient outcomes, including timely pain treatment, triage assessment, diagnostic evaluations, and interpreter use, with the overall goal of improving patient equity by REaL over time. This article presents a roadmap for a disparity reduction intervention, which can be part of a multifaceted approach to address health equity in EDs.

Patient and Visit Characteristics Associated With Physical Restraint Use in the Emergency Department

Objective Physical restraints are used in emergency departments (EDs) to address behavioral emergencies in situations in which less restrictive methods have failed. The objective of this study was to evaluate for associations between patient/visit characteristics and physical restraint use. Study Design This study was designed as a cross-sectional, retrospective study of all encounters at Kaiser Permanente Northern California EDs from January 1, 2016, to December 31, 2019, to evaluate differences in patient and visit characteristics between visits involving physical restraint use and those without. Methods Using electronic health record data, this study identified physical restraint use among ED encounters and extracted demographic, clinical, and facility characteristics. The authors calculated odds ratios for physical restraint placement, adjusting for patient and visit characteristics and accounting for within-patient clustering. Results Among 4,410,816 encounters (representing 1,791,673 patients), 6369 encounters (0.1%) involved physical restraint use among 5,554 patients (0.3%). Variables associated with the lowest odds of physical restraint included female sex, presentation to the ED in more recent years, and presence of intentional self-harm/suicidal ideation. Variables associated with the highest odds of physical restraint included higher visit acuity and weekend presentations to the ED. Discussion This study, which leveraged a large, diverse patient sample generalizable to the Northern California population, found several patient and visit characteristics associated with physical restraint use in the ED. Conclusion Results of this study may help identify patient groups and situational factors that are most likely to lead to physical restraint use and structural factors contributing to disparities in care, thereby informing interventions to reduce physical restraint use when possible.

Development of an instrument to measure awareness and mitigation of bias in maternal healthcare

BACKGROUND

Implicit bias among maternal healthcare professionals contributes to disrespectful care and racial and ethnic disparities in patient outcomes, and there is growing consensus that implicit bias training is a key component of birth equity initiatives. A requirement for implicit bias training for healthcare professionals has become more widespread, but the impact training has is largely unknown, in part, because of a lack of validated instruments. Therefore, there is an urgent need for a psychometrically valid instrument for use in the evaluation of implicit bias training.

OBJECTIVE

This study aimed to develop a valid and reliable instrument to assess implicit bias awareness and mitigation practices among maternal care professionals and that can be used to evaluate interventions aimed at mitigating such bias in clinical practice.

STUDY DESIGN

We conducted an instrument development and validation study in 3 phases. In phase 1, item development, we generated a 43-item bank from literature and consultation and established content validity with subject matter experts. In phase 2, instrument development, we administered a revised set of 33 items to 307 nurses and midwives and conducted exploratory factor analysis to demonstrate construct validity and reliability. In phase 3, instrument evaluation, we confirmed the factor structure and compared the means of implicit bias training-exposed and -unexposed participants to further demonstrate construct validity with a representative state sample of 2096 maternal healthcare professionals (physicians, midwives, and nurses).

RESULTS

Based on phase 2 results, we retained 23 items for the Bias in Maternal Health Care scale, which showed high internal consistency (Cronbach's alpha, 0.86). We identified 3 subscales, namely a 9-item Bias Awareness subscale (Cronbach's alpha, 0.86), a 7-item Bias Mitigation Practice subscale (Cronbach's alpha, 0.82), and a 7-item Bias Mitigation Self-Efficacy subscale (Cronbach's alpha, 0.81). Validation of the Bias Awareness and Bias Mitigation Practice subscales in phase 3 demonstrated the instrument's high reliability (Cronbach's alpha 0.86 and 0.83, respectively) and discriminating performance among maternal healthcare professionals.

CONCLUSION

We developed a reliable and valid instrument for measuring awareness and mitigation of bias among maternal healthcare professionals. It can be used to evaluate implicit bias training and other bias mitigation interventions in maternal healthcare settings.

Exploring Bias in Restraint Use: Four Strategies to Mitigate Bias in Care of the Agitated Patient in the Emergency Department

Agitation is a routine and increasingly common presentation to the emergency department (ED). In the wake of a national examination into racism and police use of force, this article aims to extend that reflection into emergency medicine in the management of patients presenting with acute agitation. Through an overview of ethicolegal considerations in restraint use and current literature on implicit bias in medicine, this article provides a discussion on how bias may impact care of the agitated patient. Concrete strategies are offered at an individual, institutional, and health system level to help mitigate bias and improve care. Reprinted from Acad Emerg Med 2021; 28:1061-1066, with permission from John Wiley & Sons. Copyright © 2021.

Implicit Bias Training in Health Professions Education: A Scoping Review

There is a recurrent call for effective implicit bias (IB) education within health professions education (HPE). We aimed to explore the state of IB education within HPE for clinical learners and IB educators using the Arksey and O'Malley scoping review framework. Thirty publications variable in curricular design met inclusion criteria. No studies assessed learner outcomes at the level of Miller's "shows" or "does" nor reported program evaluation outcomes at the level of Kirkpatrick's "behavior" or "results." Rigorous, theory-guided studies assessing behavioral change, patient care delivery, and patient outcomes are needed to move the field of IB education forward within HPE.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-022-01673-z.

Brief online implicit bias education increases bias awareness among clinical teaching faculty

PROBLEM AND PURPOSE

Healthcare provider implicit bias influences the learning environment and patient care. Bias awareness is one of the key elements to be included in implicit bias education. Research on education enhancing bias awareness is limited. Bias awareness can motivate behavior change. The objective was to evaluate whether exposure to a brief online course, Implicit Bias in the Clinical and Learning Environment, increased bias awareness.

MATERIALS AND METHODS

The course included the history of racism in medicine, social determinants of health, implicit bias in healthcare, and strategies to reduce the impact of implicit bias in clinical care and teaching. A sample of U.S. academic family, internal, and emergency medicine providers were recruited into the study from August to December 2019. Measures of provider implicit and explicit bias, personal and practice characteristics, and pre-post-bias awareness measures were collected.

RESULTS

Of 111 participants, 78 (70%) were female, 81 (73%) were White, and 63 (57%) were MDs. Providers held moderate implicit pro-White bias on the Race IAT (Cohen's d = 0.68) and strong implicit stereotypes associating males rather than females with 'career' on the Gender-Career IAT (Cohen's d = 1.15). Overall, providers held no explicit race bias (Cohen's d = 0.05). Providers reported moderate explicit male-career (Cohen's d = 0.68) and strong female-family stereotype (Cohen's d = 0.83). A statistically significant increase in bias awareness was found after exposure to the course (p = 0.03). Provider implicit and explicit biases and personal and practice characteristics were not associated with an increase in bias awareness.

CONCLUSIONS

Implicit bias education is effective to increase providers' bias awareness regardless of strength of their implicit and explicit biases and personal and practice characteristics. Increasing bias awareness is one step of many toward creating a positive learning environment and a system of more equitable healthcare.

Educational strategies used to improve the knowledge, skills, and attitudes of health care students and providers regarding implicit bias: An integrative review of the literature

Background

The thoughts, feelings, and attitudes health care professionals unconsciously have about patients can negatively impact patients' health outcomes. Systematic reviews related to implicit bias in health care providers have uncovered negative implicit bias towards older adults, people of color, people with disabilities, psychiatric patients, patients who are obese, people of low socioeconomic status, and women. Implicit bias impacts the quality, safety, and competence of care delivered; interactions between patients and providers; and patient approval of treatment recommendations. Health care professions students and health care providers need to participate in evidence-based educational strategies to manage and diminish bias.

Objective

To review the evidence regarding educational strategies used with health care professions students and providers to improve their knowledge of implicit bias, reduce bias, and improve attitudes about bias.

Design

Integrative review.

Methods

The literature review was completed in July 2020 with two updates performed in February 2021 and June 2021 using nine databases including Academic Search Complete™, Embase®, ERIC®, Ovid, PubMed®, Scopus®, and Web of Science™. Key terms used related to education, health care professions' students, health care providers, implicit, bias, incivility, microaggression, and microassult. Publications dates from 2011 to 2021 were included. Covidence software was used for the initial screening and for full-text analysis.

Results

Thirty-nine articles were analysed for this review. The most commonly used educational strategies to instruct about principles of implicit bias include discussion groups, simulation and case-based learning, pre-tests for awareness, use of expert facilitators, commitment to action/change, and debriefing. Common components of successful strategies include thoughtful program planning, careful selection of program facilitators (who are content experts), support of participants, and a system-level investment.

Conclusions

Diverse educational strategies successfully addressed implicit bias across studies. Recommendations for future studies includes addressing limitations in sampling strategies and data collection to clarify relationships between educational strategies and participant outcomes. Educational opportunities are warranted that challenge health care professionals to explore their implicit bias towards others in an effort to provide care that considers diversity, equity, and inclusion and also limits personal implicit bias.

Confronting implicit bias toward patients: a scoping review of post-graduate physician curricula

BACKGROUND

Physicians' behavior may unknowingly be impacted by prejudice and thereby contribute to healthcare inequities. Despite increasingly robust data demonstrating physician implicit bias (The Office of Minority Health. Minority Population Profiles, 2021; COVID-19 Shines Light on Health Disparities, National Conference of State Legislatures 2021), the evidence behind how to change this with training programs remains unclear. This scoping review therefore reports on the implementation, outcomes, and characteristics of post-graduate physician implicit bias curricula.

METHODS

The authors conducted a literature review using scoping review methodology. They searched 7 databases in February and November 2020 for English-language academic and gray literature on implicit bias curricula for physicians at all levels of post-graduate training. Ten reviewers screened studies for eligibility independently, then extracted data from these studies and compiled it into a chart and analytical summary.

RESULTS

Of the 4,599 articles screened, this review identified 90 articles on implicit bias interventions for post-graduate physicians. Inductive data analysis revealed a spectrum of educational approaches, which were categorized int o 4 educational models called Competence, Skills-Based, Social Contact, and Critical Models. The most commonly reported strength was the interactive nature of the curricula (26%), and the most frequently identified challenges were related to time and resources available (53%). Half of the interventions discussed facilitator preparation, and the majority (62%) evaluated outcomes using pre and post self-assessments.

CONCLUSIONS

This review provides a comprehensive synthesis of the literature on physician implicit bias curricula. It is our goal that this supports medical educators in applying and improving aspects of these interventions in their own programs.

A survey of implicit bias training in physician assistant and nurse practitioner postgraduate fellowship/residency programs

BACKGROUND

There has been renewed focus on advancing inclusivity within organized medicine to reduce health disparities and achieve health equity by addressing the deleterious effects of implicit bias in healthcare and clinical outcomes. It is well documented that negative implicit attitudes and stereotypes perpetuate inequity in healthcare. The aim of this study is to investigate implicit bias training in postgraduate physician assistant (PA) and nurse practitioner (NP) education; describe delivery of content to trainees; and detail program directors' attitudes toward this type of training. Although there is research examining implicit bias training in physician residency education, there are no published studies on implicit bias training in postgraduate PA and NP postgraduate residency/fellowship programs.

METHOD

A non-experimental, descriptive study was designed to obtain information via survey from members of the Association of Postgraduate Physician Assistant Programs (APPAP).

RESULTS

The response rate was 41%. The majority of respondents (76%) felt that PA and NP postgraduate programs should include implicit bias instruction. Educational strategies used by PA and joint PA/NP postgraduate programs or their sponsoring institution to deliver implicit bias content to trainees include: implicit bias training modules (50%), facilitated group discussions (36%), invited speaker on implicit bias (33%), case studies on implicit bias (16%), and implicit association test (10%); however, 30% of postgraduate programs do not provide implicit bias training to PA and/or NP trainees. Barriers to implementing implicit bias training expressed by some postgraduate programs include: uncertainty in how to incorporate implicit bias training (16%); lack of strategic alignment with training program or sponsoring institution (13%); time constraints (10%); financial constraints (6%); lack of access to content experts (6%); and unfamiliarity with evidence supporting implicit bias training (6%).

CONCLUSION

The present study sheds some light on the current state of implicit bias training in PA and joint PA/NP postgraduate residency/fellowship programs. While the majority of programs offer some sort of implicit bias training, there is a need to standardize this training in PA and joint PA/NP postgraduate education curricula using an actionable framework.

Race, But Not Gender, Is Associated With Admissions Into Orthopaedic Residency Programs

BACKGROUND

Orthopaedic surgery is one of the most competitive but least diverse surgical specialties, with ever-increasing academic achievements (such as test scores) shown by applicants. Prior research shows that white applicants had higher United States Medical Licensing Exam (USMLE) Step 1 and Step 2 Clinical Knowledge scores as well as higher odds of Alpha Omega Alpha status compared with Black, Hispanic, and other applicant groups. Yet, it still remains unknown whether differences in application metrics by race/ethnicity sufficiently explain the underrepresentation of certain racial or ethnic minority groups in orthopaedic residency programs.

QUESTIONS/PURPOSES

In this study, we sought to determine (1) the relative weight of academic variables for admission into orthopaedic residency, and (2) whether race and gender are independently associated with admission into an orthopedic residency.

METHODS

The Electronic Residency Application System (ERAS) data from the Association of American Medical Colleges (AAMC) and the National Board of Medical Examiners (NBME) of first-time MD applicants (n = 8966) for orthopaedic surgery residency positions in the United States and of admitted orthopaedic residents (n = 6218) from 2005 to 2014 were reviewed. This dataset is the first and most comprehensive of its kind to date in orthopaedic surgery. Academic metrics, such as USMLE Step 1 and Step 2 Clinical Knowledge scores, number of publications, Alpha Omega Alpha status, volunteer experiences, work experience, as well as race and gender, were analyzed using hierarchical logistic regression models. The first model analyzed the association of academic metrics with admission into orthopaedic residency. In the second model, we added race and gender and controlled for metrics of academic performance. To determine how well the models simulated the actual admissions data, we computed the receiver operating characteristics (ROC) including the area under curve (AUC), which measures the model's ability to simulate which applicants were admitted or not admitted, with an AUC = 1.0 representing a perfect simulation. The odds ratio and confidence interval of each variable were computed.

RESULTS

When only academic variables were analyzed in the first model, Alpha Omega Alpha status (odds ratio 2.12 [95% CI 1.80 to 2.50]; p < 0.001), the USMLE Step 1 score (OR 1.04 [95% CI 1.03 to 1.04]; p < 0.001), the USMLE Step 2 Clinical Knowledge score (OR 1.01 [95% CI 1.01 to 1.02]; p < 0.001), publication count (OR 1.04 [95% CI 1.03 to 1.05]; p < 0.001), and volunteer experience (OR 1.03 [95% CI 1.01 to 1.04]; p < 0.001) were associated with admissions into orthopaedics while work and research experience were not. This model yielded a good prediction of the results with an AUC of 0.755. The second model, in which the variables of race and gender were added to the academic variables, also had a good prediction of the results with an AUC of 0.759. This model indicates that applicant race, but not gender, is associated with admissions into orthopaedic residency. Applicants from Asian (OR 0.78 [95% CI 0.67 to 0.92]), Black (OR 0.63 [95% CI 0.51 to 0.77], Hispanic (OR 0.48 [95% CI 0.36 to 0.65]), or other race groups (OR 0.65 [95% CI 0.55 to 0.77]) had lower odds of admission into residency compared with white applicants.

CONCLUSION

Minority applicants, but not women, have lower odds of admission into orthopaedic surgery residency, even when accounting for academic performance metrics. Changes in the residency selection processes are needed to eliminate the lower admission probability of qualified minority applicants in orthopaedic residency and to improve the diversity and inclusion of orthopaedic surgery. Changes including increasing the diversity of the selection committee, bias training, blinding applications before review, removal of metrics with history of racial disparities from an interviewer's candidate profile before an interview, and use of holistic application review (where an applicants' experiences, attributes, and academic metrics are all considered) can improve the diversity landscape in training. In addition, cultivating an environment of inclusion will be necessary to address these long-standing trends in orthopaedic surgery.

CLINICAL RELEVANCE

Race, but not gender, is associated with the odds of acceptance into orthopaedic surgery residency despite equivalent academic metrics. Changes in residency selection processes are suggested to eliminate the lower admission probability of qualified minority applicants into orthopaedic residency and to improve the diversity and inclusion of orthopaedic surgery.

A national evaluation of emergency department thoracotomy practices: Will a high-risk, low-yield procedure reveal potential management practice bias?

BACKGROUND

Emergency department thoracotomy is often performed on patients in extremis from traumatic exsanguination. Thus, inherent biases may play a role in whether or not the emergency department thoracotomy is performed. We aimed to investigate race, socioeconomic status, and gender disparities in the use of emergency department thoracotomy and to investigate outcomes of these patients to assess for possible surgeon practice bias.

METHOD

A nationwide retrospective cohort analysis of the American College of Surgeons Trauma Quality Programs Participant Use Profile 2016-2018. Adult patients who suffered blunt, penetrating, or other injuries secondary to falls/firearms/motor vehicle collision/other mechanisms of injury and presented to a trauma center pulseless, with or without signs of life after injury. Rates of thoracotomy, time to thoracotomy, transfer to operating room, emergency department disposition, intensive care unit length of stay, hospital length of stay, complications, mortality, and hospital disposition. Univariate analyses and adjusted multivariable regression were performed to account for confounders with significance defined as P < .05.

RESULTS

A total of 6,453 patients were analyzed. Emergency department thoracotomy and mortality were significantly higher in minorities and uninsured patients, even after risk adjustment. There were no differences in timing among race groups to emergency department thoracotomy. White/Caucasian patients experienced the highest rate of emergency department initial disposition to the intensive care unit (10.3%, P < .0001) and lowest mortality rate (89.2%, P < .0001).

CONCLUSION

Surgeon bias was not seen in the practice of emergency department thoracotomy for patients arriving pulseless. However, poorer outcomes were associated with minorities and lower socioeconomic status patients. Thoracotomy rates were higher in minorities and lower socioeconomic status patients due to more penetrating trauma.

Longitudinal outcomes one year following implicit bias training in medical students

PURPOSE

Training in implicit bias is broadly recognized as important in medical education and is mandated by some accrediting bodies. This study examined medical students' retention of concepts immediately following and one-year post participation in an implicit bias workshop.

METHODS

Study subjects were 272 third-year medical students who participated in workshops held between 2018-2020 that used the Implicit Associations Test (IAT) as a trigger for discussions in small groups. We developed a survey and administered it to students to capture their awareness of implicit bias pre-, post-, and one-year post-workshop attendance. Repeated Measures Analyses and independent-samples t-tests were used to examine for differences in responses on each of the seven survey items and a tabulated 7-item average of these seven items.

RESULTS

Six of seven survey items and the tabulated 7-item average examined by Repeated Measures Analyses showed statistically significant increases between the pre-, post-, and one-year post-surveys (ps range: 0.01-0.07), with a small to moderate effect sizes (ƞ_p²s range: 0.01-0.07). Pairwise comparisons among these three surveys' results indicated statistically significant improvements between the pre- and the post-workshop surveys (ps range: 0.01-0.03) but no statistically significant differences between the post- and the one-year post-workshop surveys (ps range: 0.57-0.99). A separate sample of 17 off-cycle students who took the one-year post- workshop survey two years after the workshop did not differ statistically on the level of awareness of bias compared to those taking the same survey one year later, as examined by the two-group independent t-tests for the seven one-year post-workshop survey items (ps range: 0.56-0.99).

CONCLUSIONS

The findings support one-year retention of knowledge and attitudes gained from an implicit bias workshop and suggest similar retention at two years. Future educational interventions that train learners to recognize and manage implicit and explicit behaviors in clinical practice are needed.

Notions About Men and Masculinities Among Health Care Professionals Working With Men's Sexual Health: A Focus Group Study

Health care professionals’ (HCPs) notions about gender may influence the provision and quality of care. If care-seeking men are met by HCPs holding idealized and stereotypical notions of masculinity, this could reinforce barriers to adequate care. This study explored notions about men and masculinities among HCPs working with men’s sexual health in Sweden. Focus group interviews with 35 HCPs from primary health and sexual health clinics were analyzed using qualitative content analysis. The analysis resulted in three descriptive themes: (a) Contradictory masculinity—elusive but clear. Notions of masculinity as a phenomenon or concept were elusive, but masculine and un-masculine traits, behaviors, and qualities were clear. (b) Sexual health care is a social place where men and masculinities can be challenging. Male patients were associated with unwanted sexual tensions. Masculinity could challenge professionality. Seeking sexual health care was perceived as doing un-masculinity. (c) Regarding masculinity as irrelevant—a difficult ambition to achieve. Participants strived for gender-neutrality by regarding patients as humans, individuals, or patients rather than as men and masculine. The analysis also identified a theme of meaning: Notions of masculinity are situated relationally. HCPs situate masculinity in real and hypothetical relationships. Romantic and sexual preferences were used to define preferred masculinity. This study identified themes that showed how HCPs balanced professional and private notions of men and masculinity in their patient encounters. Increased gender awareness and training are needed to professionalize the management of gendered notions in encounters with men who seek care for sexual health problems.

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

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

Cultural Competency Curricula in US Graduate Medical Education: A Scoping Review

BACKGROUND

Cultural competency training provides participants with knowledge and skills to improve cross-cultural communication and is required for all graduate medical education (GME) training programs.

OBJECTIVE

The authors sought to determine what cultural competency curricula exist specifically in GME.

METHODS

In April 2020, the authors performed a scoping review of the literature using a multidatabase (PubMed, Ovid, MedEdPORTAL) search strategy that included keywords relevant to GME and cultural competency. The authors extracted descriptive data about the structure, implementation, and analysis of cultural competency curricula and analyzed these data for trends.

RESULTS

Sixty-seven articles met criteria for inclusion, of which 61 (91%) were focused exclusively on residents. The most commonly included specialties were psychiatry (n=19, 28.4%), internal medicine (n=16, 23.9%), and pediatrics (n=15, 22.4%). The shortest intervention was a 30-minute online module, while the longest contained didactics, electives, and mentoring programs that spanned the entirety of residency training (4 years). The sample sizes of included studies ranged from 6 to 833 participants. Eight (11.9%) studies utilized OSCEs as assessment tools, while 17 (25.4%) conducted semi-structured interviews or focus groups. Four common themes were unique interventions, retention of learning, trainee evaluation of curricula, and resources required for implementation.

CONCLUSIONS

Wide variation exists in the design, implementation, and evaluation of cultural competency curricula for residents and fellows.

Half the picture: Word frequencies reveal racial differences in clinical documentation, but not their causes

Clinical notes are the best record of a provider's perceptions of their patients, but their use in studying racial bias in clinical documentation has typically been limited to manual evaluation of small datasets. We investigated the use of computational methods to scale these insights to large, heterogeneous clinical text data. We found significant differences in negative emotional tone and language implying social dominance in clinical notes between Black and White patients, but identified multiple contributing factors in addition to potential provider bias, including mis-categorization of some healthcare vocabulary as emotion-related. We further found that notes for Black patients were significantly less likely to mention opioids than for White patients, potentially reflecting both inequitable access to medication and provider bias. Our analysis showed that computational tools have significant potential for studying racial bias in large clinical corpora, and identified key challenges to providing a nuanced analysis of bias in clinical documentation.

The reduction of race and gender bias in clinical treatment recommendations using clinician peer networks in an experimental setting

Bias in clinical practice, in particular in relation to race and gender, is a persistent cause of healthcare disparities. We investigated the potential of a peer-network approach to reduce bias in medical treatment decisions within an experimental setting. We created "egalitarian" information exchange networks among practicing clinicians who provided recommendations for the clinical management of patient scenarios, presented via standardized patient videos of actors portraying patients with cardiac chest pain. The videos, which were standardized for relevant clinical factors, presented either a white male actor or Black female actor of similar age, wearing the same attire and in the same clinical setting, portraying a patient with clinically significant chest pain symptoms. We found significant disparities in the treatment recommendations given to the white male patient-actor and Black female patient-actor, which when translated into real clinical scenarios would result in the Black female patient being significantly more likely to receive unsafe undertreatment, rather than the guideline-recommended treatment. In the experimental control group, clinicians who were asked to independently reflect on the standardized patient videos did not show any significant reduction in bias. However, clinicians who exchanged real-time information in structured peer networks significantly improved their clinical accuracy and showed no bias in their final recommendations. The findings indicate that clinician network interventions might be used in healthcare settings to reduce significant disparities in patient treatment.

Racial disparities in non-recommendation of adjuvant chemotherapy in stage II-III ovarian cancer

OBJECTIVES

To identify patient factors associated with not receiving a recommendation for adjuvant chemotherapy after primary surgery for ovarian cancer.

METHODS

This retrospective cohort study used the National Cancer Database (NCDB) data from 2004 to 2015 to identify patients with stage II-III ovarian cancer who underwent primary surgery. Multivariate logistic regression analyses evaluated factors associated with notation in the NCDB that "chemotherapy was not recommended/administered because it was contraindicated due to patient risk factors (i.e., comorbid conditions, advanced age)." Survival data were assessed via Kaplan-Meier analyses.

RESULTS

Of the 48,245 patients who met the inclusion criteria, 522 (1.08%) did not receive adjuvant chemotherapy because it was determined to be contraindicated. In multivariate analyses, independent predictors for not receiving a recommendation for adjuvant chemotherapy were age ≥ 70 years old (adjusted odds ratio, aOR = 2.43, p < 0.0001), non-zero Charlson-Deyo comorbidity scores (score 1, aOR = 1.41, p = 0.002; score ≥ 2, aOR = 2.57, p < 0.0001), and Black race (aOR = 2.12, p < 0.0001). For Black patients, recommendation against adjuvant chemotherapy occurred at a younger median age (64.5 years vs. 72 years) and was associated with lower 5-year survival (25.9% vs. 40.3%, p < 0.0001).

CONCLUSIONS

Patients with ovarian cancer who underwent surgery but did not receive chemotherapy "because it was contraindicated due to patient risk factors" were older and had higher comorbidity scores. Even after controlling for these differences, Black patients were disproportionately not recommended for chemotherapy, which was associated with worse survival. Determining eligibility for adjuvant chemotherapy requires an individualized approach, and the possible influence of racial bias on risk estimation should be further investigated.

Exploring bias in restraint use: Four strategies to mitigate bias in care of the agitated patient in the emergency department

Agitation is a routine and increasingly common presentation to the emergency department (ED). In the wake of a national examination into racism and police use of force, this article aims to extend that reflection into emergency medicine in the management of patients presenting with acute agitation. Through an overview of ethicolegal considerations in restraint use and current literature on implicit bias in medicine, this article provides a discussion on how bias may impact care of the agitated patient. Concrete strategies are offered at an individual, institutional, and health system level to help mitigate bias and improve care.

The impact of racism on emergency health care workers

INTRODUCTION

Discrimination based on race is a known source of stress in individuals and is a contributor to poor health outcomes in patients. However, less is known about how the experiences of racism impact the stress levels of emergency health care workers (EHCWs).

OBJECTIVES

The goal of this study was to assess the impact that racism has on the stress of EHCWs.

METHODS

An anonymous electronic cross-sectional survey of EHCWs including attending physicians, resident physicians, advanced practice providers, nurses, and staff at three large metropolitan hospitals was administered in the summer of 2020. The survey evaluated the stress related to systemic racism and the COVID-19 pandemic in addition to the wellness measures utilized to cope with these stressors. The focus of this article is the impact of systemic racism on EHCWs.

RESULTS

Of the 576 eligible participants, the total number of respondents utilized for analysis was 260. Overall, 64% of participants were very concerned about the state of racism in the United States, and 30% reported moderate-high or high stress resulting from racism. When stratified by race, 46% of Black participants reported moderate-high or high stress resulting from racism, compared to 31% of other participants of color and 23% of White participants (p = 0.002).

CONCLUSION

Systemic racism is a significant concern and source of stress for EHCWs. Additional research about systemic racism, its impact on medical providers, and more importantly, active strategies to reduce and ultimately eliminate it in health care is needed.

Solutions: Bridging the Diversity Gap in Urology Trainees

OBJECTIVES

To address healthcare inequities, diversifying the physician workforce is an important step and improved efforts to recruit Underrepresented in Medicine (URiM) students is vital. We aim to examine the current state of minority recruitment and provide solutions to increase diversity in urology residency training.

METHODS

We conducted a retrospective analysis of self-reported race and ethnicity data for active urology trainees using the Data Resource Book by the Accreditation Council of Graduate Medical Education from 2011-2020. We also performed a longitudinal analysis comparing the number of urology applicants to urology trainees from 2016 to 2020 using the Electronic Residency Application Service statistics database. URiMs were designated in alignment with ACGME definitions. Categorical variables were summarized as frequencies and percentages and compared using chi-squared test between race and ethnicity.

RESULTS

We identified 11,458 active urology trainees for analysis. Of these, 6638 (57.9%) identified as White, 1690 (14.7%) as Asian/Pacific Islander, 442 (3.9%) as Hispanic, 380 (3.3%) as Black, 11 (0.1%) as Native American, 608 (5.3%) as other race/ethnicity and 1689 (14.7%) as unknown race or ethnicity. In 2011, 8.1% of trainees identified as URiM which remains the same at 8.2% in 2020.

CONCLUSIONS

As we strive to improve patient care and support our URiM colleagues, diversity, equity, and inclusion must be prioritized. Despite increases in students entering medical school and the expansion of urology training spots, the numbers of URiM in urologic training remains stubbornly unchanged. This work highlights an area of residency training that requires critical transformation.

Strategies to Enhance Diversity, Equity, and Inclusion in Pathology Training Programs: A Comprehensive Review of the Literature

CONTEXT.—

Like many medical specialties, pathology faces the ongoing challenge of effectively enriching diversity, equity, and inclusion within training programs and the field as a whole. This issue is furthered by a decline in US medical student interest in the field of pathology, possibly attributable to increasingly limited pathology exposure during medical school and medical student perceptions about careers in pathology.

OBJECTIVE.—

To review the literature to identify the challenges to diversity, equity, and inclusion in pathology, with an emphasis on the pathology trainee pipeline. To evaluate the medical education literature from other medical specialties for diversity and inclusion-focused studies and initiatives, and determine the outcomes and/or approaches relevant for pathology training programs.

DATA SOURCES.—

A literature review was completed by a search of the PubMed database, as well as a similar general Google search. Additional resources, including the Web sites of the Association of American Medical Colleges, the Electronic Residency Application Service, and the National Resident Matching Program, were used.

CONCLUSIONS.—

Many strategies exist to increase diversity and encourage an inclusive and equitable training environment, and many of these strategies may be applied to the field of pathology. Interventions such as increasing exposure to the field, using a holistic application review process, and addressing implicit biases have been shown to promote diversity, equity, and inclusion in many medical specialties. In addition, increasing access to elective and pipeline programs may help to bolster medical student interest in careers in pathology.

Validity evidence for a novel instrument assessing medical student attitudes toward instruction in implicit bias recognition and management

BACKGROUND

Implicit bias instruction is becoming more prevalent in health professions education, with calls for skills-based curricula moving from awareness and recognition to management of implicit bias. Evidence suggests that health professionals and students learning about implicit bias ("learners") have varying attitudes about instruction in implicit bias, including the concept of implicit bias itself. Assessing learner attitudes could inform curriculum development and enable instructional designs that optimize learner engagement. To date, there are no instruments with evidence for construct validity that assess learner attitudes about implicit bias instruction and its relevance to clinical care.

METHODS

The authors developed a novel instrument, the Attitude Towards Implicit Bias Instrument (ATIBI) and gathered evidence for three types of construct validity- content, internal consistency, and relationship to other variables.

RESULTS

Authors utilized a modified Delphi technique with an interprofessional team of experts, as well as cognitive interviews with medical students leading to item refinement to improve content validity. Seven cohorts of medical students, N = 1072 completed the ATIBI. Psychometric analysis demonstrated high internal consistency (α = 0.90). Exploratory factor analysis resulted in five factors. Analysis of a subset of 100 medical students demonstrated a moderate correlation with similar instruments, the Integrative Medicine Attitude Questionnaire (r = 0.63, 95% CI: [0.59, 0.66]) and the Internal Motivation to Respond Without Prejudice Scale (r = 0.36, 95% CI: [0.32, 0.40]), providing evidence for convergent validity. Scores on our instrument had low correlation to the External Motivation to Respond Without Prejudice Scale (r = 0.15, 95% CI: [0.09, 0.19]) and the Groningen Reflection Ability Scale (r = 0.12, 95% CI: [0.06, 0.17]) providing evidence for discriminant validity. Analysis resulted in eighteen items in the final instrument; it is easy to administer, both on paper form and online.

CONCLUSION

The Attitudes Toward Implicit Bias Instrument is a novel instrument that produces reliable and valid scores and may be used to measure medical student attitudes related to implicit bias recognition and management, including attitudes toward acceptance of bias in oneself, implicit bias instruction, and its relevance to clinical care.

Rethinking diversity, equity and inclusion in an acute care surgery setting

N/A - This is the first place essay contest winner for the American Association for the Surgery of Trauma (AAST) Diversity, Equity, and Inclusion Committee's 2020 essay contest in response to the prompt 'How can diversity, equity, and inclusion be improved in acute care surgery/the AAST?' The essay does not have an attached abstract.

Ethnic Disparities in Imaging Utilization at Diagnosis of Non-Small Cell Lung Cancer

BACKGROUND

Prior research demonstrated statistically significant racial disparities related to lung cancer treatment and outcomes. We examined differences in initial imaging and survival between blacks, Hispanics, and non-Hispanic whites.

METHODS

The linked Surveillance, Epidemiology, and End Results-Medicare database between 2007 and 2015 was used to compare initial imaging modality for patients with lung cancer. Participants included 28 881 non-Hispanic whites, 3123 black, and 1907 Hispanics, patients age 66 years and older who were enrolled in Medicare fee-for-service and diagnosed with lung cancer. The primary outcome was comparison of positron emission tomography (PET) imaging with computerized tomography (CT) imaging use between groups. A secondary outcome was 12-month cancer-specific survival. Information on stage, treatment, and treatment facility was included in the analysis. Chi-square test and logistic regression were used to evaluate factors associated with imaging use. Kaplan-Meier method and Cox proportional hazards regression were used to calculate adjusted hazard ratios and survival. All statistical tests were two-sided.

RESULTS

After adjusting for demographic, community, and facility characteristics, blacks were less likely to undergo PET or CT imaging at diagnosis compared with non-Hispanic whites odds ratio (OR) = 0.54 (95% confidence interval [CI] = 0.50 to 0.59; P < .001). Hispanics were also less likely to receive PET with CT imaging (OR = 0.72, 95% CI = 0.65 to 0.81; P < .001). PET with CT was associated with improved survival (HR = 0.61, 95% CI = 0.57 to 0.65; P < .001).

CONCLUSIONS

Blacks and Hispanics are less likely to undergo guideline-recommended PET with CT imaging at diagnosis of lung cancer, which may partially explain differences in survival. Awareness of this issue will allow for future interventions aimed at reducing this disparity.