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Joseph I, Johns AJ, Kleber K, Luce S, Godoy L, Fannon EE. Operating on A Bias: A Review of Cultural Competency Curricula in Surgical Residencies and a Call for Systemic Change. JOURNAL OF SURGICAL EDUCATION 2024; 81:1249-1257. [PMID: 38944584 DOI: 10.1016/j.jsurg.2024.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 03/18/2024] [Accepted: 06/02/2024] [Indexed: 07/01/2024]
Abstract
BACKGROUND Several factors contribute to surgical outcome disparities, including structural racism and implicit bias. Research into how surgical residency programs intervene on Cultural Complications via education remains sparse. We review the literature for how surgical residency programs use education to combat staff and patient exposure to Cultural Complications. METHODS We searched PubMed, SCOPUS, and Google Scholar for curricula aimed at improving cultural competency in surgical residencies. OBGYN curricula were included. Non-US studies were excluded. RESULTS Studies were organized by intervention type: Didactic, Grand Rounds, and M&M. The most common interventions were Didactics, with Grand Rounds being the least common. Target measures improved anywhere from 20-88%. CONCLUSIONS The common types of cultural competency curricula are clear, and certain interventions show improvement in trainees' education. Scarcity of data on these curricula does not necessarily indicate their lack of existence but does suggest additional research is needed into curricular interventions and how they may address cultural complications.
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Affiliation(s)
- Ian Joseph
- University of California, Davis, Department of Surgery, Sacramento, California 95817.
| | - Alexandra J Johns
- University of California, Davis, Department of Surgery, Sacramento, California 95817
| | - Kara Kleber
- University of California, Davis, Department of Surgery, Sacramento, California 95817
| | - Siobhan Luce
- University of California, Davis, Department of Surgery, Sacramento, California 95817
| | - Luis Godoy
- University of California, Davis, Department of Surgery, Sacramento, California 95817
| | - Elise Eh Fannon
- University of California, Davis, Department of Surgery, Sacramento, California 95817
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Hagiwara N, Duffy C, Cyrus J, Harika N, Watson GS, Green TL. The nature and validity of implicit bias training for health care providers and trainees: A systematic review. SCIENCE ADVANCES 2024; 10:eado5957. [PMID: 39141723 PMCID: PMC11323883 DOI: 10.1126/sciadv.ado5957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 07/09/2024] [Indexed: 08/16/2024]
Abstract
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.
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Affiliation(s)
- Nao Hagiwara
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA 22903, USA
| | - Conor Duffy
- Department of Psychology, Virginia Commonwealth University, Richmond, VA 23284, USA
| | - John Cyrus
- Research and Education Department, Health Sciences Library, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Nadia Harika
- Department of Pediatrics, Virginia Commonwealth University, Richmond, VA 23219, USA
| | - Ginger S. Watson
- Virginia Modeling Analysis & Simulation Center, Old Dominion University, Suffolk, VA 23435, USA
| | - Tiffany L. Green
- Departments of Population Health Sciences and Obstetrics and Gynecology, University of Wisconsin-Madison, Madison, WI 53726, USA
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Gupta A, Thompson JC, Ringel NE, Kim-Fine S, Ferguson LA, Blank SV, Iglesia CB, Balk EM, Secord AA, Hines JF, Brown J, Grimes CL. Sexual Harassment, Abuse, and Discrimination in Obstetrics and Gynecology: A Systematic Review. JAMA Netw Open 2024; 7:e2410706. [PMID: 38717770 PMCID: PMC11079690 DOI: 10.1001/jamanetworkopen.2024.10706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 03/09/2024] [Indexed: 05/12/2024] Open
Abstract
Importance Unlike other surgical specialties, obstetrics and gynecology (OB-GYN) has been predominantly female for the last decade. The association of this with gender bias and sexual harassment is not known. Objective To systematically review the prevalence of sexual harassment, bullying, abuse, and discrimination among OB-GYN clinicians and trainees and interventions aimed at reducing harassment in OB-GYN and other surgical specialties. Evidence Review A systematic search of PubMed, Embase, and ClinicalTrials.gov was conducted to identify studies published from inception through June 13, 2023.: For the prevalence of harassment, OB-GYN clinicians and trainees on OB-GYN rotations in all subspecialties in the US or Canada were included. Personal experiences of harassment (sexual harassment, bullying, abuse, and discrimination) by other health care personnel, event reporting, burnout and exit from medicine, fear of retaliation, and related outcomes were included. Interventions across all surgical specialties in any country to decrease incidence of harassment were also evaluated. Abstracts and potentially relevant full-text articles were double screened.: Eligible studies were extracted into standard forms. Risk of bias and certainty of evidence of included research were assessed. A meta-analysis was not performed owing to heterogeneity of outcomes. Findings A total of 10 eligible studies among 5852 participants addressed prevalence and 12 eligible studies among 2906 participants addressed interventions. The prevalence of sexual harassment (range, 250 of 907 physicians [27.6%] to 181 of 255 female gynecologic oncologists [70.9%]), workplace discrimination (range, 142 of 249 gynecologic oncologists [57.0%] to 354 of 527 gynecologic oncologists [67.2%] among women; 138 of 358 gynecologic oncologists among males [38.5%]), and bullying (131 of 248 female gynecologic oncologists [52.8%]) was frequent among OB-GYN respondents. OB-GYN trainees commonly experienced sexual harassment (253 of 366 respondents [69.1%]), which included gender harassment, unwanted sexual attention, and sexual coercion. The proportion of OB-GYN clinicians who reported their sexual harassment to anyone ranged from 21 of 250 AAGL (formerly, the American Association of Gynecologic Laparoscopists) members (8.4%) to 32 of 256 gynecologic oncologists (12.5%) compared with 32.6% of OB-GYN trainees. Mistreatment during their OB-GYN rotation was indicated by 168 of 668 medical students surveyed (25.1%). Perpetrators of harassment included physicians (30.1%), other trainees (13.1%), and operating room staff (7.7%). Various interventions were used and studied, which were associated with improved recognition of bias and reporting (eg, implementation of a video- and discussion-based mistreatment program during a surgery clerkship was associated with a decrease in medical student mistreatment reports from 14 reports in previous year to 9 reports in the first year and 4 in the second year after implementation). However, no significant decrease in the frequency of sexual harassment was found with any intervention. Conclusions and Relevance This study found high rates of harassment behaviors within OB-GYN. Interventions to limit these behaviors were not adequately studied, were limited mostly to medical students, and typically did not specifically address sexual or other forms of harassment.
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Affiliation(s)
- Ankita Gupta
- Division of Urogynecology, University of Louisville Health, Louisville, Kentucky
| | - Jennifer C. Thompson
- Division of Urogynecology, Department of Obstetrics and Gynecology, Northwest Kaiser Permanente, Portland, Oregon
| | - Nancy E. Ringel
- Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Shunaha Kim-Fine
- Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Lindsay A. Ferguson
- Division of Gynecologic Oncology, University Hospitals Cleveland Medical Center/Case Western Reserve University, Cleveland, Ohio
| | - Stephanie V. Blank
- Division of Gynecologic Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Cheryl B. Iglesia
- Division of Urogynecology, MedStar Health, Washington, District of Columbia
- Department of Obstetrics and Gynecology, Georgetown University School of Medicine, Washington, District of Columbia
| | - Ethan M. Balk
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island
| | - Angeles Alvarez Secord
- Division of Gynecologic Oncology, Duke University Medical Center, Duke Cancer Institute, Durham, North Carolina
| | - Jeffrey F. Hines
- University of Connecticut Health Center, Farmington, Connecticut
| | - Jubilee Brown
- Atrium Health Levine Cancer, Charlotte, North Carolina
| | - Cara L. Grimes
- Department of Obstetrics and Gynecology, New York Medical College and Westchester Medical Center, Valhalla, New York
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Snee I, Hakimi A, Malekzadeh S. Prevalence of and Barriers to Health Disparities Education Among Otolaryngology Residency Curricula. OTO Open 2024; 8:e148. [PMID: 38826640 PMCID: PMC11143485 DOI: 10.1002/oto2.148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 05/03/2024] [Accepted: 05/17/2024] [Indexed: 06/04/2024] Open
Abstract
Objective To assess the prevalence of health disparities curricula in otolaryngology residency programs and identify implementation barriers. Study Design Cross-sectional survey. Setting National otolaryngology residency programs. Methods A survey based on published literature discussing the incorporation of health disparities curricula, educational design, quality, barriers to implementation, and patient demographics was sent to US otolaryngology residency program directors (PDs). Otolaryngology programs excluded from consideration included those of osteopathic recognition, programs outside of the United States, and military programs. In excluding osteopathic, international, and military-based residency programs from our survey, we aimed to maintain sample homogeneity and focus our analysis on allopathic programs due to potential variations in demographic compositions and practice settings. This decision was made to ensure a more targeted examination of health disparities within a specific context, aligning with our research objectives and resource constraints. Anonymous survey results were collected and analyzed to determine the prevalence of health disparities curricula as well as their effectiveness and standardization across residency programs. Results A total of 24 PDs (response rate, 23%) responded to the survey. Half of the PDs reported having a health disparities curriculum, among whom only 25% felt the quality of their curriculum was very good or excellent. All institutions with an explicit health disparities educational program reported having developed their own curriculum, 75% of which changed annually. However, 92% of these programs reported not measuring outcomes to assess their curriculum's utility. The most reported barriers to curriculum development for all programs included insufficient time (63%), limited teaching ability specific to health disparities education (54%), and faculty disinterest in teaching (33%). Conclusion Very few of the surveyed otolaryngology residency programs have implemented a health disparities curriculum. A comprehensive and standardized health disparities curriculum would be beneficial to ensure that residents can confidently develop competency in health disparities, aligning with the Clinical Learning Environment Review mandate and Accreditation Council for Graduate Medical Education expectations.
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Affiliation(s)
- Isabel Snee
- Department of Otolaryngology–Head and Neck SurgeryMedStar Georgetown University HospitalWashingtonDistrict of ColumbiaUSA
| | - Amir Hakimi
- Department of Otolaryngology–Head and Neck SurgeryMedStar Georgetown University HospitalWashingtonDistrict of ColumbiaUSA
| | - Sonya Malekzadeh
- Department of Otolaryngology–Head and Neck SurgeryMedStar Georgetown University HospitalWashingtonDistrict of ColumbiaUSA
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Kruse JA, Collins JL, Vugrin M. 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. INTERNATIONAL JOURNAL OF NURSING STUDIES ADVANCES 2022; 4:100073. [PMID: 38745633 PMCID: PMC11080399 DOI: 10.1016/j.ijnsa.2022.100073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 02/11/2022] [Accepted: 03/02/2022] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
| | | | - Margaret Vugrin
- Health Sciences Center- Preston Smith Library, Texas Tech University, United States
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Curran T, Zhang J, Gebregziabher M, Taber DJ, Marsden JE, Booth A, Magwood GS, Mauldin PD, Baliga PK, Lockett MA. Surgical Outcomes Improvement and Health Inequity in a Regional Quality Collaborative. J Am Coll Surg 2022; 234:607-614. [PMID: 35290280 DOI: 10.1097/xcs.0000000000000084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Surgical quality improvement initiatives may impact sociodemographic groups differentially. The objective of this analysis was to assess the trajectory of surgical morbidity by race and age over time within a Regional Collaborative Quality Initiative. STUDY DESIGN Adults undergoing eligible general surgery procedures in South Carolina Surgical Quality Collaborative hospitals were analyzed for the presence of at least 1 of 22 morbidities between August 2015 and February 2020. Surgery-level multivariable logistic regression assessed the racial differences in morbidity over time, stratified by age group (18 to 64 years, 65 years and older), and adjusting for potential patient- and surgical-level confounders. RESULTS A total of 30,761 general surgery cases were analyzed, of which 28.4% were performed in Black patients. Mean morbidity rates were higher for Black patients than non-Black patients (8.5% vs 6.0%, p < 0.0001). After controlling for race and other confounders, a significant decrease in monthly mean morbidity through time was observed in each age group (odds ratio [95% CI]: age 18 to 64 years, 0.986 [0.981 to 0.990]; age 65 years and older, 0.991 [0.986 to 0.995]). Comparing morbidity rates from the first 4 months of the collaborative to the last 4 months reveals older Black patients had an absolute decrease in morbidity of 6.2% compared with 3.6% for older non-Black patients. Younger Black patients had an absolute decrease in morbidity of 4.7% compared with a 3.0% decrease for younger non-Black patients. CONCLUSIONS Black patients had higher morbidity rates than non-Black patients even when controlling for confounders. The reasons for these disparities are not apparent. Morbidity improved over time in all patients with older Black patients seeing a larger absolute decrease in morbidity.
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Affiliation(s)
- Thomas Curran
- From the College of Medicine (Curran, Zhang, Gebregziabher, Taber, Marsdan, Booth, Mauldin, Baliga, Lockett), Medical University of South Carolina, Charleston, SC
| | - Jingwen Zhang
- From the College of Medicine (Curran, Zhang, Gebregziabher, Taber, Marsdan, Booth, Mauldin, Baliga, Lockett), Medical University of South Carolina, Charleston, SC
| | - Mulugeta Gebregziabher
- From the College of Medicine (Curran, Zhang, Gebregziabher, Taber, Marsdan, Booth, Mauldin, Baliga, Lockett), Medical University of South Carolina, Charleston, SC
| | - David J Taber
- From the College of Medicine (Curran, Zhang, Gebregziabher, Taber, Marsdan, Booth, Mauldin, Baliga, Lockett), Medical University of South Carolina, Charleston, SC
| | - Justin E Marsden
- From the College of Medicine (Curran, Zhang, Gebregziabher, Taber, Marsdan, Booth, Mauldin, Baliga, Lockett), Medical University of South Carolina, Charleston, SC
| | - Alexander Booth
- From the College of Medicine (Curran, Zhang, Gebregziabher, Taber, Marsdan, Booth, Mauldin, Baliga, Lockett), Medical University of South Carolina, Charleston, SC
| | - Gayenell S Magwood
- College of Nursing (Magwood), Medical University of South Carolina, Charleston, SC
| | - Patrick D Mauldin
- From the College of Medicine (Curran, Zhang, Gebregziabher, Taber, Marsdan, Booth, Mauldin, Baliga, Lockett), Medical University of South Carolina, Charleston, SC
| | - Prabhakar K Baliga
- From the College of Medicine (Curran, Zhang, Gebregziabher, Taber, Marsdan, Booth, Mauldin, Baliga, Lockett), Medical University of South Carolina, Charleston, SC
| | - Mark A Lockett
- From the College of Medicine (Curran, Zhang, Gebregziabher, Taber, Marsdan, Booth, Mauldin, Baliga, Lockett), Medical University of South Carolina, Charleston, SC
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Kratzke IM, Portelli Tremont JN, Marulanda K, Carter TM, Reid TD, Perez AJ, Kapadia MR. Healthcare Disparity Education for Surgical Residents: Progress Made, More Needed. J Am Coll Surg 2022; 234:182-188. [PMID: 35213439 DOI: 10.1097/xcs.0000000000000041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Healthcare disparities are an important determinant of patient outcomes yet are not standardized within surgical resident education. This study aimed to determine the prevalence and design of current healthcare disparities curricula for surgical residents and included a resident-based needs assessment at a single institution. STUDY DESIGN A national survey evaluating the presence and design of healthcare disparities curricula was distributed to general surgery program directors via the Association of Program Directors in Surgery Listserv. A related survey was administered to all general surgery residents at a single academic institution. RESULTS One hundred forty-six program directors completed the survey, with 68 (47%) reporting an active curriculum. The most frequently taught topic is regarding patient race as a healthcare disparity, found in 63 (93%) of existing curricula. Fifty-two (76%) of the curricula were implemented within the last 3 years. Of the 78 (53%) programs without a curriculum, 8 (10%) program directors stated that their program would not benefit from one. Thirty-four (45%) of the programs without a curriculum cited institutional support and time as the most common barriers to implementation. Of the 23 residents who completed the survey, 100% desired learning practical knowledge regarding healthcare disparities relating to how race and socioeconomic status affect the clinical outcomes of surgical patients. CONCLUSIONS Less than half of general surgery training programs have implemented healthcare disparities curricula. Resident preferences for the format and content of curricula may help inform program leaders and lead to comprehensive national standards.
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Affiliation(s)
- Ian M Kratzke
- From the Department of Surgery, University of North Carolina, Chapel Hill, NC
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