Eliminating Explicit and Implicit Biases in Health Care: Evidence and Research Needs

Perceptions of homelessness: Is there variation across medical careers and specialties?

INTRODUCTION

Medical students, residents and faculty are all capable of holding biases towards stigmatised groups like people experiencing homelessness. This study sought to investigate how the level of training may influence perceptions of homelessness among medical students, residents and faculty. Additionally, we sought to understand how different specialities perceive people experiencing homelessness and whether this changes at various points in a career.

METHODS

The Health Professionals' Attitudes Towards the Homeless Inventory (HPATHI) was administered to medical students, residents and faculty at one institution in the United States. Basic demographics as well as length of time spent in practice were collected in addition to HPATHI responses.

RESULTS

A total of 1,141 individuals were invited to complete the survey, including 736 medical students, 214 residents and 191 faculty. Two hundred and ninety individuals participated in the survey and 238 recorded complete responses were analysed for a sample response rate of 238/1141 (20.9%.) Overall perceptions of homelessness across the entire sample were positive and not greatly influenced by the level of training during a medical career. Medical students across classes were largely in agreement and there was a noticeable increase in positive perceptions for students engaged in clinical rotations. However, clinical specialties demonstrated wide variation in perceptions, with the most prominent differences amongst individuals from surgical subspecialties of General Surgery and Obstetrics & Gynaecology.

CONCLUSION

Our study demonstrates the largely favourable attitudes physicians, residents and students have towards people experiencing homelessness with implications for future work to support greater exposure to underserved populations during training. Specialty choice appears to play a larger role in the formation of attitudes towards underserved populations rather than the length of time spent in a particular specialty.

The relationship between race and emergency medical services resuscitation intensity for those in refractory-arrest

Background

Previous studies have reported race-based health disparities in North America. It is unknown if emergency medical service (EMS) treatment of out-of-hospital cardiac arrest (OHCA) varies based on race. We sought to compare markers of resuscitation intensity among different racial groups.

Methods

Using data of adult EMS-treated OHCAs from the Trial of Continuous or Interrupted Chest Compressions During CPR, we analyzed data from participants for whom on-scene return of spontaneous circulation (ROSC) was not achieved. We fit multivariate regression models using a generalized estimating equation, to estimate the association between patient race (White vs. Black vs. "Other") and the following markers for resuscitation intensity: (1) resuscitation attempt duration; (2) intra-arrest transport; (3) number of epinephrine doses; (4) EMS arrival-to-CPR interval, and (5) 9-1-1 to first shock.

Results

From our study cohort of 5370 cases, the median age was 65 years old (IQR: 53-78), 2077 (39 %) were women, 2121 (39 %) were Black, 596 (11 %) were "Other race", 2653 (49 %) were White, and 4715 (88 %) occurred in a private location. With reference to White race, Black race was associated with a longer resuscitation attempt duration and a lower number of epinephrine doses; Black and "Other" race were both associated with a lower odds of intra-arrest transport.

Conclusion

We identified race-based differences in EMS resuscitation intensity for OHCA within a North American cohort, although 40% of race data was missing from this dataset. Future research investigating race-based differences in OHCA management may be warranted.

Factors affecting U.S. adults' comfort level in sharing social needs information with healthcare providers

OBJECTIVE

This study examines various factors affecting U.S. adults' comfort level in sharing information about their social needs with healthcare providers.

METHODS

We used data from the 2022 Health Information National Trends Survey (cycle 6), a nationally representative survey of U.S. adults (n = 6252). The outcome variables were participants' comfort level in sharing information about three social needs (food insecurity, transportation difficulties, and housing instability). Data were analyzed using weighted bivariate and multivariable logistic regression models.

RESULTS

Participants who faced discrimination when getting medical care based on race/ethnicity were more likely to be uncomfortable in sharing information about food insecurity, housing instability, and transportation difficulties. Those who trusted the healthcare system "a lot" were less likely to be uncomfortable in sharing information about food insecurity and transportation difficulties. Patient-Centered Communication (PCC) and social isolation scores significantly affected participants' comfort level in sharing information about social needs.

CONCLUSION

Various factors such as trust, discrimination, social isolation, and PCC were found to be significantly affecting US adults' comfort level in sharing information about social needs.

PRACTICE IMPLICATIONS

Healthcare systems and policymakers should focus on developing approaches and strategies to enhance trust, reduce discrimination, improve patient-provider communication, and create supportive social environments.

Assessing Facility Readiness to Provide Equitable Birthing Care in New York State: A Baseline Survey

CONTEXT

Facility policies, practices, and culture contribute to inequities in maternal outcomes. In New York State (NYS), Black birthing people are 4 to 5 times more likely to experience maternal mortality than White birthing people.

OBJECTIVES

Understanding the racial, ethnic, linguistic, and gender equity policies at NYS birthing facilities can identify areas of improvement to impact care and outcomes.

DESIGN

The design was a cross-sectional study.

SETTING

The setting was NYS birthing facilities, which included hospitals and birthing centers.

PARTICIPANTS

Facility leadership completed self-reported surveys from December 2020 through June 2021.

MAIN OUTCOME MEASURE

Facility equity data were obtained across 4 domains: (1) organizational commitment to equity, (2) staff equity training and evaluation, (3) leadership and staff composition, and (4) patient data, voice, and influence.

RESULTS

Over half of NYS birthing facilities documented a public commitment to equity in their mission, but only 15% had a written equity plan with processes for monitoring progress. Less than one-third of facilities stated that staff from underrepresented racial, ethnic, and language, gender (REaLG) groups were proportionally represented in leadership and management positions. About half of the facilities reported their staff composition reflects their patient population, but only a quarter analyzed staff REaLG demographics to serve diverse patients. Twenty-eight percent of facilities assess diversity in their board of directors, facility leadership, medical leadership, medical staff, and administrative staff. One-third required staff implicit bias training; 17% collected and used data on patient satisfaction regarding racial equity; and 12% engaged affected communities.

CONCLUSIONS

Facilities differed in their implementation of policies and practices that support equitable care. Survey data provide facilities with specific areas of improvement to focus their efforts. Equity assessments are an important step for facilities to evaluate their policies and practices and for statewide institutions to develop programming.

"I Think Many of Them Want to Appear to Have a Growth Mindset": Exploring Supervisors' Perceptions of Feedback-Seeking Behavior

PURPOSE

Feedback seeking is an expected learner competency. Motivations to seek feedback are well explored, but we know little about how supervisors perceive such requests for feedback. These perceptions matter because how supervisors judge requests can affect the feedback they give. This study explores how supervisors perceive and attribute motivations behind feedback requests to better understand the benefits and hazards of feedback seeking.

METHOD

Constructivist grounded theory was used to interview supervisors at the Temerty Faculty of Medicine, University of Toronto, from February 2020 to September 2022. Supervisors were asked to describe instances when they perceived feedback requests as being sincere or insincere, what led to their opinions, and how they responded. Transcripts were analyzed and coded in parallel with data collection; data analysis was guided by constant comparison.

RESULTS

Seventeen faculty were interviewed. Participants perceived 4 motivations when learners sought feedback: affirmation or praise; a desire to improve; an administrative requirement, such as getting forms filled out; and hidden purposes, such as making a good impression. These perceptions were based on assumptions regarding the framing of the initial request; timing; preexisting relationship with the learner; learner characteristics, such as insecurity; and learner reactions to feedback, particularly defensiveness. Although being asked for feedback was generally well received, some participants reported irritation at requests that were repetitive, were poorly timed, or did not appear sincere.

CONCLUSIONS

Feedback seeking may prompt supervisors to consider learners' motivations, potentially resulting in a set of entangled attributions, assumptions, and reactions that shape the feedback conversation in invisible and potentially problematic ways. Learners should consider these implications as they frame their feedback requests and be explicit about what they want and why they want it. Supervisors should monitor their responses, ask questions to clarify requests, and err on the side of assuming feedback-seeking requests are sincere.

County-level racial bias is associated with worse care for white and especially black older US adults: a cross-sectional observational study

OBJECTIVE

To assess the association of county-level bias about black and white people with patient experience, influenza immunisation, and quality of clinical care for black and white older US adults (age 65+ years).

DESIGN

Linear multivariable regression measured the cross-sectional association of county-level estimates of implicit and explicit bias about black and white people with patient experiences, influenza immunisation, and clinical quality-of-care for black and white older US adults.

PARTICIPANTS

We used data from 1.9 million white adults who completed implicit and explicit bias measures during 2003-2018, patient experience and influenza immunisation data from respondents to the 2009-2017 Medicare Consumer Assessment of Healthcare Providers and Systems (MCAHPS) Surveys, and clinical quality-of-care data from patients whose records were included in 2009-2017 Healthcare Effectiveness Data and Information Set (HEDIS) submissions (n=0.8-2.9 million per measure).

MAIN OUTCOME MEASURES

Three patient experience measures and patient-reported influenza immunisation from the MCAHPS Survey; five HEDIS measures.

RESULTS

In county-level models, higher pro-white implicit bias was associated with lower immunisation rates and worse scores for some patient experience measures for black and white adults as well as larger-magnitude black-white disparities. Higher pro-white implicit bias was associated with worse scores for some HEDIS measures for black and white adults but not with black-white disparities in clinical quality of care. Most significant associations were small in magnitude (effect sizes of 0.2-0.3 or less).

CONCLUSIONS

To the extent that county-level pro-white implicit bias is indicative of bias among healthcare providers, there may be a need for interventions designed to prevent such bias from adversely affecting the experiences and preventive care of black patients and the clinical quality of care for all patients.

Evaluating for Evidence of Sociodemographic Bias in Conversational AI for Mental Health Support

The integration of large language models (LLMs) into healthcare highlights the need to ensure their efficacy while mitigating potential harms, such as the perpetuation of biases. Current evidence on the existence of bias within LLMs remains inconclusive. In this study, we present an approach to investigate the presence of bias within an LLM designed for mental health support. We simulated physician-patient conversations by using a communication loop between an LLM-based conversational agent and digital standardized patients (DSPs) that engaged the agent in dialogue while remaining agnostic to sociodemographic characteristics. In contrast, the conversational agent was made aware of each DSP's characteristics, including age, sex, race/ethnicity, and annual income. The agent's responses were analyzed to discern potential systematic biases using the Linguistic Inquiry and Word Count tool. Multivariate regression analysis, trend analysis, and group-based trajectory models were used to quantify potential biases. Among 449 conversations, there was no evidence of bias in both descriptive assessments and multivariable linear regression analyses. Moreover, when evaluating changes in mean tone scores throughout a dialogue, the conversational agent exhibited a capacity to show understanding of the DSPs' chief complaints and to elevate the tone scores of the DSPs throughout conversations. This finding did not vary by any sociodemographic characteristics of the DSP. Using an objective methodology, our study did not uncover significant evidence of bias within an LLM-enabled mental health conversational agent. These findings offer a complementary approach to examining bias in LLM-based conversational agents for mental health support.

"First, Trust Needs to Develop": Hematologists' Perspectives on Factors Influencing Black Persons' Participation in Clinical Trials

BACKGROUND

Cancer clinical trials are crucial for treatment standards and innovation but lack racial-ethnic diversity. Understanding physician perspectives on recruiting participants is critical due to their role in decision-making about trial candidacy and enrollment.

METHODS

From August 2021 to January 2022 we recruited 13 Academic hematologists experienced with treating blood cancers and enrolling clinical trial participants. Each hematologist participated in a 60-75-minute semistructured interview and completed a sociodemographic survey. Using the National Institute on Minority Health and Health Disparities multilevel model as a framework, we characterized hematologists' perceived barriers to clinical trial participation among Black persons. ATLAS.ti v9 and later v 23.2.1 was used for project management and to facilitate data analysis using the Sort and Sift, Think and Shift approach (ResearchTalk Inc).

RESULTS

All hematologists were White, with 70% being male. Three factors influenced their perspectives on enrolling Black individuals in clinical trials: individual attitudes and beliefs, such as perceptions that Black or socioeconomically disadvantaged persons will be less willing or less compliant with the requirements for trial participation and follow-up. The need to build trusting relationships between themselves and patients prior to discussing clinical trials and the prevailing legacy of medical mistrust among the Black community. Trust was found to be the underlying factor in determining communication between hematologists and Black persons about clinical trials across all three levels.

CONCLUSION

This study highlights how hematologists' attitudes, beliefs, biases, and views on trust in patient relationships influence their communication with Black individuals about clinical trials. It emphasizes the need for further research to develop interventions that address the lack of racial and ethnic diversity in trials.

Latine Immigrant Perspectives on Trust of Clinical Research

Introduction: Medical mistrust impedes minority group participation in research, but there are few studies assessing determinants of Latine immigrants' trust in the clinical research enterprise. This qualitative study explored Latine immigrants' perspectives of clinical research. Methods: We conducted telephonic interviews with 20 Latine immigrants receiving care at a Federally Qualified Health Center in Los Angeles, California. Interviews were conducted between December 2021 and April 2022, and resultant data were coded using thematic analysis. Results: Six main themes emerged across two domains. First, trust was influenced by perceptions of the investigators' intentions. These perceptions were primarily based on (1) adequacy of information provided about the research, (2) perceived intent of investigators to respect their humanity, and (3) opportunities to share personal experiences. Second, trust was influenced by perceptions of the study's potential impact, including (4) risk of adverse outcomes, including health risks and risk of immigration status exposure, (5) perceived personal benefits, and (6) perceived community-level benefits. Conclusion: Researchers can build trust and promote participation among Latine immigrants by effectively communicating study objectives, risk mitigation efforts, and personal and community benefits. Enhancing the trustworthiness of clinical research can increase the relevance of scientific findings, representing one pathway to achieving health equity.

A Systematic Review of the Relationship Between Discrimination, Racism, and Type 2 Diabetes Healthcare Outcomes for Black Americans

BACKGROUND

Disparities in type 2 diabetes (T2DM) risk, care, and complications impact Black Americans more than that of their White counterparts. This study aims to examine the association between discrimination, racism, and T2DM care and outcomes in Black Americans.

METHOD

The systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.

RESULTS

A total of six original research articles met the inclusion criteria, comprising three quantitative and three qualitative studies. Overall, the systematic review findings revealed that among Black Americans, perceived interpersonal discrimination and racism by healthcare professionals are associated with patients' behaviors that impact T2DM outcomes. The findings also revealed that provider-level factors such as communication, provider assumptions and attitudes, information sharing, shared decision-making, and disease management behaviors might influence T2DM outcomes in this population.

DISCUSSION

Better T2DM-related outcomes depend on optimal disease control through adequate disease management. Building a therapeutic and culturally appropriate relationship free of discrimination and racism is vital for optimal disease management and decreasing health disparities in this patient population.

CONCLUSION

Perceived interpersonal racism and discrimination by healthcare providers, among other sociocultural factors, play a crucial role in influencing some patient behaviors that affect T2DM health outcomes in this population. Efforts to decrease health disparities in this specific community should also focus on interventions addressing provider-level factors and behaviors perceived as racist or discriminatory.

Effectiveness of the uChicago Health Inequity Classification System on surgical morbidity and mortality conference: A pilot study

BACKGROUND

Across surgery, marginalized individuals experience worse postoperative outcomes. These disparities stem from the interplay between multiple factors.

METHODS

We introduced a novel framework to assess the role of barriers to access and bias in surgical complications (the uChicago Health Inequity Classification System, CHI-CS) in the setting of morbidity and mortality conference and assessed impact through pre and post implementation surveys.

RESULTS

Access and bias were related to surgical complications in 14 ​% of cases. 97 ​% reported enhanced M&M presentations with the grading system, and 47 ​% reported a change in decision-making or practice style. Although post-implementation response rate was low, there were improvements in self-reported confidence and comfort in recognizing and discussing these issues.

CONCLUSIONS

Implementation of the CHI-CS framework to discuss bias and access to care positively impacted the way providers view, discuss, and process health inequities.

"It's just as remarkable as being left-handed, isn't it?": exploring normativity through Australian physiotherapists' perspectives of working with LGBTQIA+ patients

INTRODUCTION

Individuals identifying as lesbian, gay, bisexual, transgender, queer, intersex, asexual and other related identities (LGBTQIA+) experience challenges with healthcare, including physiotherapy. To understand potential contributions to poor experiences, this study explored physiotherapists' experiences and perspectives about working with members of LGBTQIA+ communities.

METHODS

This study employed a qualitative research design, suitable for exploring the experiences and perspectives of individuals within the physiotherapy context. The sample consisted of physiotherapists working in Australia who participated in a larger survey study. Data were collected via semi-structured interviews which were audio-recorded and transcribed verbatim. Data analysis was conducted using a relativistic and queer theoretical framework with a reflexive thematic approach.

RESULTS

Eighteen physiotherapists with diverse sexual orientations participated in the interviews. While all participants identified as women or men, not all used binary gender pronouns. Five key themes were developed: 1) "anti-discrimination" regarding choice of language and providing safe environments; 2) "current and historical discrimination" against LGBTQIA+ individuals; 3) "taking an equality approach" when working with LGBTQIA+ patients; 4) "knowledge of LGBTQIA+ health" in a broad sense and specifically with transgender and gender-diverse people; and 5) "managing own reactions" with respect to individual biases and discomfort.

CONCLUSION

Underpinning all themes was the overarching concept of cis/hetero/endonormativity. Assuming normativity when working with LGBTQIA+ patients, is likely to have negative effects on patients' mental health, the therapeutic relationship and quality of care. In order to improve diversity, safety, inclusion and equity of care for LGBTQIA+ individuals, it is vital that normativity within physiotherapy is challenged.

Ending Unequal Treatment and Achieving Optimal Health for All

This Viewpoint discusses the findings of a recent National Academies of Sciences, Engineering, and Medicine report suggesting that current health care delivery and accountability structures perpetuate, rather than reduce, health inequities and details several changes needed to address these structural problems.

Addressing Bias in the Occupational Therapy Admissions Process

This study investigated the impact of a workshop in reducing unconscious bias in admissions committee members of an occupational therapy program to determine if workshop participation increased the number of underrepresented students in the program. A convenience sample of 50 committee members was used. A Wilcoxon matched pairs signed rank test indicated a significant increase in the post-test survey question scores. A chi-square test of independence revealed a significant increase in the number of students in the program from underrepresented groups. These results suggest that an online workshop can reduce perceived bias and increase diversity in an occupational therapy program.

Challenging Misconceptions about Race in Undergraduate Genetics

Racial biases, which harm marginalized and excluded communities, may be combatted by clarifying misconceptions about race during biology lessons. We developed a human genetics laboratory activity that challenges the misconception that race is biological (biological essentialism). We assessed the relationship between this activity and student outcomes using a survey of students' attitudes about biological essentialism and color-evasive ideology and a concept inventory about phylogeny and human diversity. Students in the human genetics laboratory activity showed a significant decrease in their acceptance of biological essentialism compared with a control group, but did not show changes in color-evasive ideology. Students in both groups exhibited increased knowledge in both areas of the concept inventory, but the gains were larger in the human genetics laboratory. In the second iteration of this activity, we found that only white students' decreases in biological essentialist beliefs were significant and the activity failed to decrease color-evasive ideologies for all students. Concept inventory gains were similar and significant for both white and non-white students in this iteration. Our findings underscore the effectiveness of addressing misconceptions about the biological origins of race and encourage more research on ways to effectively change damaging student attitudes about race in undergraduate genetics education.

Bias, Prejudice, Discrimination, Racism, and Social Determinants: The Impact on the Health and Well-Being of Latino Children and Youth

This narrative review focuses on the impact of bias, prejudice, discrimination, racism (BPDR), social determinants of health, and structural racism on Latino children's health and well-being. The race/ethnicity, country of origin, immigrant/generational status, limited English proficiency (LEP), acculturation level, and social class of Latino children and their parents can heighten or modify the impact of BPDR. These differences have been shown to affect BPDR among Latino adults and presumably for their children. Surveys of Latino adolescents reveal that 60% have experienced discrimination, with first- and second-generation teens having a higher prevalence. These experiences are magnified by adverse social determinants/structural racism. BPDR can impact Latino children prenatally through adolescence. Bias involving neonatal, primary, and inpatient pediatric services has been reported. In 2021, Latino children were 19% less likely to complete preventive care, and 32% of LEP children had no medical home. School-age Latino children experience system inequities associated with chronic physical and mental health conditions. BPDR is also seen in educational performance but can be buffered by a strong racial/ethnic self-identity. To address BPDR/structural racism for Latino children, we suggest pediatricians: 1) increase the Latino child-health workforce to address BPDR internally and externally, 2) advocate for data collection on and monitoring of Latino children's disparities and racism metrics in pediatric services, to improve quality of care for Latino children and their families, and 3) advocate for child health equity. Together, these steps will help eliminate BPDR for Latino children and ensure they obtain their full potential.

Diversity, Equity, and Inclusion: Obstetrics and Gynecologist Hospitalists' Impact on Maternal Mortality

Obstetrics and gynecology hospitalists play a vital role in reducing maternal morbidity and mortality by providing immediate access to obstetric care, especially in emergencies. Their presence in hospitals ensures timely interventions and expert management, contributing to better outcomes for mothers and babies. This proactive approach can extend beyond hospital walls through education, advocacy, and community outreach initiatives aimed at improving maternal health across diverse settings.

Understanding Implicit Bias and Its Impact in Veterinary Medicine

Implicit biases are those we are unwilling to admit, yet they influence our behavior in ways that impact our experience in the workplace. Literature demonstrates that implicit bias influences career choice and limits success within a chosen career. Discrimination in the veterinary workplace is pervasive and has a negative impact that is responsible for financial loss. It can also influence client communication, patient-care, and be inadvertently perpetuated by well-meaning community clinics. Strategies can be employed to acknowledge implicit bias and to foster behavioral change, which results in a healthier workplace and improved client and patient-care.

The pervasive influence of systems of power on transition readiness for adult care in sickle cell disease: A qualitative study

BACKGROUND

Adolescence and young adulthood are vulnerable developmental periods for individuals with sickle cell disease (SCD), particularly given the impact of social inequities, challenges with transitioning to adult healthcare services, and increased risk for morbidity and mortality. Systems of power, such as institutionalized and interpersonal manifestations of bias, could impact SCD transfer and engagement in adult care through their influence on healthcare transition readiness; yet research in this area is limited.

OBJECTIVE

To characterize how systems of power impact transition readiness factors described in the Social-ecological Model of AYA Readiness for Transition to Promote Health Equity (SMART-E) framework at the patient, caregiver, and practitioner levels.

METHODS

Pediatric adolescents and young adults (AYA), transferred AYA, caregivers, and practitioners participated in semi-structured focus groups and individual interviews examining health equity and systems of power during healthcare transition. Focus groups/interviews were transcribed and coded using a deductive approach via the updated SMART-E framework.

RESULTS

Ten pediatric AYA with SCD, nine transferred AYA with SCD, eight caregivers, and nine practitioners participated in a focus group or interview. Qualitative findings across reporters emphasize the impact of systems of power (e.g., racial bias and disease stigma) on knowledge, skills and self-efficacy, beliefs and expectations, goals and motivation, and emotions and psychosocial functioning at the patient, caregiver, and practitioner levels.

CONCLUSION

Systems of power are prevalent with respect to transition barriers for AYA with SCD and their supports. Structural, institutional, and individual factors with potential to reduce the influence of systems of power should be further identified and targeted for intervention.

LT4/LT3 Combination Therapy vs. Monotherapy with LT4 for Persistent Symptoms of Hypothyroidism: A Systematic Review

Regardless of the cause, hypothyroidism should be treated with levothyroxine. The objectives of management are the normalization of TSH levels and the relief of symptoms. In general, the vast majority of patients who achieve normalization of TSH levels show a resolution of symptoms; however, for a small number of individuals, symptoms persist (despite adequate control of TSH). This scenario generates a dilemma in the therapeutic approach to these patients, because even when excluding other causes or concomitant diseases that can explain the persistence of symptoms, pharmacological management strategies are scarce. Consequently, the efficacy of some less conventional approaches to therapy, such as the use of LT3 monotherapy, desiccated thyroid extracts, and LT4/LT3 combinations, in addressing persistent hypothyroid symptoms have been evaluated in multiple studies. The majority of these studies did not observe a significant benefit from these "nonconventional" therapies in comparison to results with LT4 monotherapy alone. Nevertheless, some studies report that a significant proportion of patients prefer an alternative to monotherapy with LT4. The most common approach has been to prescribe a combination of LT4 and LT3, and this review describes and analyzes the current evidence of the efficacy of LT4/LT3 combination therapy vs. LT4 monotherapy in addressing persistent hypothyroidism symptoms to provide suggested guidelines for clinicians in the management of these patients.

Understanding the Association Between Medical Mistrust and Unmet Medical Care Need in Gender and Sexually Diverse People of Color Assigned Female at Birth

Purpose: The present study investigated associations of sexual orientation and/or gender identity-based medical mistrust and racial/ethnic-based medical mistrust, respectively, with unmet medical care need among lesbian, gay, bisexual, transgender, queer, and/or sexually or gender diverse (LGBTQ+) people of color (POC) assigned female at birth (AFAB). We also tested the interaction of the two types of medical mistrust on unmet medical care need. Methods: Participants were 266 LGBTQ+ POC AFAB. Participants completed measures of medical mistrust based on race/ethnicity and LGBTQ+ identity. Unmet medical care need was assessed using the item: "During the past 12 months, was there ever a time where you felt that you needed health care but you didn't receive it?" Multivariate logistic regression models were run with either type of medical mistrust, as well as their interaction, as the predictor and unmet medical care need as the outcome variable. Results: There were no significant main effects of either type of medical mistrust on unmet medical care need. However, there was an interaction between the two types of medical mistrust, such that associations between each type of medical mistrust and unmet medical care needs were stronger at higher levels of the other type of medical mistrust. Racial/ethnic medical mistrust was associated with a greater likelihood of unmet medical needs at high, but not low, levels of LGBTQ+ medical mistrust. Conclusions: Racial/ethnic medical mistrust and LGBTQ+ medical mistrust exacerbate each other's influence on unmet medical care need. These results underscore the need for inclusive clinical practices for LGBTQ+ POC.

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.

Are clinicians ethically obligated to disclose their use of medical machine learning systems to patients?

It is commonly accepted that clinicians are ethically obligated to disclose their use of medical machine learning systems to patients, and that failure to do so would amount to a moral fault for which clinicians ought to be held accountable. Call this 'the disclosure thesis.' Four main arguments have been, or could be, given to support the disclosure thesis in the ethics literature: the risk-based argument, the rights-based argument, the materiality argument and the autonomy argument. In this article, I argue that each of these four arguments are unconvincing, and therefore, that the disclosure thesis ought to be rejected. I suggest that mandating disclosure may also even risk harming patients by providing stakeholders with a way to avoid accountability for harm that results from improper applications or uses of these systems.

Beyond the Question: Reexamining a Parent's Unusual Request

Pediatricians sometimes think about medical ethics as the field of determining right and wrong in in answering difficult moral questions that occur at the bedside. But an emphasis on rapidly determining right and wrong when faced with ethical dilemmas can lead clinicians to miss important issues underlying both the question and their approach to answering it. We argue that ethical reflection is not merely a process of getting to the right answer but also a way to probe beyond the original question to better understand the stakeholders' perspectives and priorities. In this Ethics Rounds, we present the case of an infant born at 23 weeks' gestation who initially faced numerous complications of prematurity, but has progressed beyond acute critical illness. His father requests a transition to palliative care at a point this option would not typically be offered. The straightforward response to this father's request is "no." However, we reexamine the father's request from the perspective of a neonatologist, a clinical ethicist, and a conflict mediator. Why is the father making this request? Why do clinicians feel rushed to respond? The authors discuss how elements of surprise and implicit biases can push clinicians to hasty answers. We introduce tools used in clinical ethics consultation and conflict mediation that can facilitate alternative responses from the clinical team. Employing the "Ladder of Inference," ascertaining the "View from Everywhere," and differentiating positions from interests can help clinicians explore the context of ethical questions and lead to more fruitful resolutions.

Rationale, design, and participant characteristics of the FAITH! Heart Health+ study: An exploration of the influence of the social determinants of health, stress, and structural racism on African American cardiovascular health

BACKGROUND

African Americans (AAs) face cardiovascular health (CVH) disparities linked to systemic racism. The 2020 police killing of Mr. George Floyd in Minneapolis, Minnesota, alongside the COVID-19 pandemic, exacerbated adverse psychosocial factors affecting CVH outcomes among AAs. This manuscript describes the study protocol and participant characteristics in an ancillary study exploring the relationship between biopsychosocial factors and CVH among AAs.

METHODS

Using a community-based participatory approach, a mixed-methods ancillary study of 58 AA participants from an overarching randomized control trial (RCT) was conducted. Baseline RCT health assessments (November 2020) provided sociodemographic, medical, and clinical data. Subsequent health assessments (February-December 2022) measured sleep quality, psychosocial factors (e.g., high-effort coping), biomarkers (e.g., cortisol), and cardiovascular diagnostics (e.g., cardio-ankle vascular index). CVH was assessed using the American Heart Association Life's Simple 7 (LS7) (range 0 to 14, poor to ideal) and Life's Essential 8 (LE8) scores (range 0 to 100, low to high). Correlations between these scores will be examined. Focus group discussions via videoconferencing (March to April 2022) assessed psychosocial and structural barriers, along with the impact of COVID-19 and George Floyd's killing on daily life.

RESULTS

Participants were predominantly female (67%), with a mean age of 54.6 [11.9] years, high cardiometabolic risk (93% had overweight/obesity and 70% hypertension), and moderate LE8 scores (mean 57.4, SD 11.5).

CONCLUSION

This study will enhance understanding of the associations between biopsychosocial factors and CVH among AAs in Minnesota. Findings may inform risk estimation, patient care, and healthcare policies to address CVD disparities in marginalized populations.

Psychosocial Factors That Influence a Woman's Decision to Enroll in a Clinical Trial: Implications on How to Improve Clinical Trial Enrollment Among Black Women

PURPOSE

Black women with breast cancer often present with more aggressive disease compared with other races, contributing to an increased risk of cancer mortality. Despite this inequity, Black women remain severely underrepresented in breast cancer clinical trials. We aim to characterize factors that influence a woman's decision to enroll in a clinical trial, with the goal of identifying clinical interventions to aid in the recruitment of vulnerable groups.

METHODS AND MATERIALS

A cross-sectional, descriptive study was conducted using a questionnaire adapted from 2 prevalidated surveys investigating factors influencing clinical trial enrollment. The survey was administered to women with curable breast cancer during a single follow-up visit at 4 different sites within a university medical system where all patients are screened for clinical trial eligibility. Chi-square tests and Mann-Whitney U tests were used to assess associations or differences between the populations.

RESULTS

One hundred ninety-four out of 209 women completed the survey, giving a compliance rate of 93%. Twenty-six percent of women self-identified as Black, most women were located at community sites (67.1%), most women had diagnoses of early-stage disease (I: 57.7%, II: 29.4%), and 81% of women had some collegiate-level education. Black women were younger at diagnosis (P = .005) and less likely to be married (P = .012) but more often lived with family members (P = .003) and had a lower median income (P < .001). According to the survey, Black women were less likely to trust their care team (P = .032), more likely to believe that research ultimately harms minorities (P < .001), and had a stronger belief in God's will determining illness and wellness (P < .001). Recurring themes of trust in the health care team, patient education, and advancement of cancer treatments were discussed in the focus groups.

CONCLUSIONS

Failure to offer clinical trials and mistrust in research institutions may pose the greatest hindrances to the enrollment of Black women in clinical trials. Empowering women through education and fostering trustworthy relationships can encourage greater clinical trial participation.

A multi-component intervention to reduce bias during family planning visits: qualitative insights on implementation from Burkina Faso, Pakistan and Tanzania

Beyond Bias was an intervention introduced in Burkina Faso, Pakistan and Tanzania, with the aim of reducing health worker bias toward young, unmarried and nulliparous women seeking family planning services. This study used qualitative methods - based on interviews with health workers who participated in the intervention, managers at health facilities that participated in the intervention, and policy and program stakeholders at the national level - to understand implementation experiences with the intervention. The results offer insights for organizations or countries seeking to implement Beyond Bias or similar programs, and point to some other key implementation challenges for multi-component interventions in lower-resource settings. The intervention, developed using a human-centered design approach, was seen as key for successful implementation but there were logistical challenges. The digital intervention was disruptive and distracting to many. In addition, the non-financial rewards intervention was perceived as complex, and some participants expressed feeling discouraged when they did not receive a reward. Beyond Bias did not sufficiently attend to the "outer setting," and this was perceived as a major implementation barrier as it limited individuals' capacity to fully achieve the desired behavior change; for example, space constraints meant that some health facilities could not ensure private services for all clients. There were scalability concerns related to cost, and there is uncertainty whether diversity of contexts (within and across countries) might constrain implementation of Beyond Bias at scale.

Investigation of health inequities in maternal and neonatal outcomes of patients with placenta accreta spectrum: a multicenter study

BACKGROUND

Placenta accreta spectrum is associated with significant maternal and neonatal morbidity and mortality. There is limited established data on healthcare inequities in the outcomes of patients with placenta accreta spectrum.

OBJECTIVE

This study aimed to investigate health inequities in maternal and neonatal outcomes of pregnancies with placenta accreta spectrum.

STUDY DESIGN

This multicentered retrospective cohort study included patients with a histopathological diagnosis of placenta accreta spectrum at 4 regional perinatal centers between January 1, 2013, and June 30, 2022. Maternal race and ethnicity were categorized as either Hispanic, non-Hispanic Black, non-Hispanic White, or Asian or Pacific Islander. The primary outcome was a composite adverse maternal outcome: transfusion of ≥4 units of packed red blood cells, vasopressor use, mechanical ventilation, bowel or bladder injury, or mortality. The secondary outcomes were a composite adverse neonatal outcome (Apgar score of <7 at 1 minute, morbidity, or mortality), gestational age at placenta accreta spectrum diagnosis, and planned delivery by a multidisciplinary team. Multivariable logistic regression was used to estimate the associations of race and ethnicity with maternal and neonatal outcomes.

RESULTS

A total of 408 pregnancies with placenta accreta spectrum were included. In 218 patients (53.0%), the diagnosis of placenta accreta spectrum was made antenatally. Patients predominantly self-identified as non-Hispanic White (31.6%) or non-Hispanic Black (24.5%). After adjusting for institution, age, body mass index, income, and parity, there was no difference in composite adverse maternal outcomes among the racial and ethnic groups. Similarly, adverse neonatal outcomes, gestational age at prenatal diagnosis, rate of planned delivery by a multidisciplinary team, and cesarean hysterectomy were similar among groups.

CONCLUSION

In our multicentered placenta accreta spectrum cohort, race and ethnicity were not associated with inequities in composite maternal or neonatal morbidity, timing of diagnosis, or planned multidisciplinary care. This study hypothesized that a comparable incidence of individual risk factors for perinatal morbidity and geographic proximity reduces potential inequities that may exist in a larger population.

Design and pilot test of an implicit bias mitigation curriculum for clinicians

Introduction

Clinician implicit racial bias (IB) may lead to lower quality care and adverse health outcomes for Black patients. Educational efforts to train clinicians to mitigate IB vary widely and have insufficient evidence of impact. We developed and pilot-tested an evidence-based clinician IB curriculum, "REACHing Equity."

Methods

To assess acceptability and feasibility, we conducted an uncontrolled one-arm pilot trial with post-intervention assessments. REACHing Equity is designed for clinicians to: (1) acquire knowledge about IB and its impact on healthcare, (2) increase awareness of one's own capacity for IB, and (3) develop skills to mitigate IB in the clinical encounter. We delivered REACHing Equity virtually in three facilitated, interactive sessions over 7-9 weeks. Participants were health care providers who completed baseline and end-of-study evaluation surveys.

Results

Of approximately 1,592 clinicians invited, 37 participated, of whom 29 self-identified as women and 24 as non-Hispanic White. Attendance averaged 90% per session; 78% attended all 3 sessions. Response rate for evaluation surveys was 67%. Most respondents agreed or strongly agreed that the curriculum objectives were met, and that REACHing Equity equipped them to mitigate the impact of implicit bias in clinical care. Participants consistently reported higher self-efficacy for mitigating IB after compared to before completing the curriculum.

Conclusions

Despite apparent barriers to clinician participation, we demonstrated feasibility and acceptability of the REACHing Equity intervention. Further research is needed to develop objective measures of uptake and clinician skill, test the impact of REACHing Equity on clinically relevant outcomes, and refine the curriculum for uptake and dissemination.ClinicalTrials.gov ID: NCT03415308.

Novel Integration of a Health Equity Immersion Curriculum in Medical Training

Health disparities education is an integral and required part of medical professional training, and yet existing curricula often fail to effectively denaturalize injustice or empower learners to advocate for change. We discuss a novel collaborative intervention that weds the health humanities to the field of health equity. We draw from the health humanities an intentional focus retraining provider imaginations by centering patient narratives; from the field of health equity, we draw the linkage between stigmatized social identities and health disparities. We describe a longitudinal health equity curriculum for the Hospice and Palliative Medicine fellowship in Memphis, Tennessee, to give trainees exposure to the concept of structural violence and how it affects clinical care. The curriculum was developed in partnership with humanities and social sciences faculty who staff a Health Equity academic program at a small liberal arts college in Memphis. This curriculum has been implemented for the past four years in support of 22 hospice and palliative medicine fellows. Group debriefs and a mixed methods survey have revealed widespread and lasting impact towards understanding health equity concepts, enhanced communication and treatment of patients, and empowerment to address the broader needs and policies affecting patients and the communities in which they live. Ultimately, we model an educational initiative that integrates equity across the full scope of healthcare practice and equips learners with skills for sustaining compassionate practices, focusing on equity-oriented, person-centered care across the full scope of healthcare practice.

Unconscious bias in speaker introductions at a national vascular surgery meeting: The impact of rank, race and gender

OBJECTIVES

Unconscious bias can impact manner of speaker introductions in formal academic settings. We examined speaker introductions at the Society of Vascular Surgeons Annual Meeting to determine factors associated with non-professional address.

METHODS

We examined speaker introductions from the 2019 SVS Vascular Annual Meeting. Professional title with either full name or last name was considered professional address. Speaker and moderator demographics were collected. Univariate and multivariate logistic regression analyses were performed to identify associations between introduction and speaker and moderator characteristics.

RESULTS

336 talks met inclusion criteria. Both speakers and moderators were more likely to be white (63.4 ​% and 65.8 ​%,p ​= ​0.92), man (75.6 ​% and 74.4 ​%,p ​= ​0.82) and full professor rank (34.5 ​% and 42.3 ​%, p ​< ​0.001). On multivariable regression, non-professional address was associated with speaker rank of trainee (OR 3.13, p ​= ​0.05) and when moderator was white (OR 2.42, p ​= ​0.03).

CONCLUSIONS

This study emphasizes the potential negative impact of unconscious bias at a national meeting for vascular surgeons and the need to mitigate this effect at the organization level.

Barriers and facilitators to involvement in cancer education opportunities among South Carolina cancer care professionals: A cancer training and diversity, equity, and inclusion training needs assessment

INTRODUCTION

It is estimated that 1.9 million new cases of cancer will be diagnosed in 2023, with 33,890 occurring in South Carolina. Assessing the needs, barriers, and facilitators of healthcare professionals' (HCP) education in South Carolina is a step towards creating meaningful, equity-promoting cancer-based education/training.

METHODS

We developed a mixed-methods REDCap survey instrument to assess HCP needs, which we disseminated via email to HCPs from divisions involved in cancer care in a South Carolina academic medical center health system. We analyzed quantitative data with univariate frequency analysis and employed an inductive content analysis approach for qualitative data.

RESULTS

The response rate for the survey was 33.0% (95/284) and 44.2% (42/95) of respondents reported a perceived barrier to attending educational programming, with majority citing time. Most respondents (71.8%) self-identified as non-Hispanic White. HCPs reported having clear interests in trainings, particularly ones focused on additional training in diversity, equity, and inclusion (DEI). Other identified educational needs included cancer treatment updates, nutrition, mental health, and social risk factors. Receiving credits for the trainings was a motivator for both general topics and DEI topics (94.7% and 74.7%, respectively).

CONCLUSIONS

There is a need to better align cancer education delivery for HCPs with their training needs and busy schedules as has been a demonstrated want by HCPs in topics that would increase knowledge and practice of DEI. As majority of respondents identified as non-Latine White, it is imperative to diversify the knowledge of the workforce to ensure that HCPs provide optimal care to patients from diverse backgrounds.

Variation in monitoring: Glucose measurement in the ICU as a case study to preempt spurious correlations

OBJECTIVE

Health inequities can be influenced by demographic factors such as race and ethnicity, proficiency in English, and biological sex. Disparities may manifest as differential likelihood of testing which correlates directly with the likelihood of an intervention to address an abnormal finding. Our retrospective observational study evaluated the presence of variation in glucose measurements in the Intensive Care Unit (ICU).

METHODS

Using the MIMIC-IV database (2008-2019), a single-center, academic referral hospital in Boston (USA), we identified adult patients meeting sepsis-3 criteria. Exclusion criteria were diabetic ketoacidosis, ICU length of stay under 1 day, and unknown race or ethnicity. We performed a logistic regression analysis to assess differential likelihoods of glucose measurements on day 1. A negative binomial regression was fitted to assess the frequency of subsequent glucose readings. Analyses were adjusted for relevant clinical confounders, and performed across three disparity proxy axes: race and ethnicity, sex, and English proficiency.

RESULTS

We studied 24,927 patients, of which 19.5% represented racial and ethnic minority groups, 42.4% were female, and 9.8% had limited English proficiency. No significant differences were found for glucose measurement on day 1 in the ICU. This pattern was consistent irrespective of the axis of analysis, i.e. race and ethnicity, sex, or English proficiency. Conversely, subsequent measurement frequency revealed potential disparities. Specifically, males (incidence rate ratio (IRR) 1.06, 95% confidence interval (CI) 1.01 - 1.21), patients who identify themselves as Hispanic (IRR 1.11, 95% CI 1.01 - 1.21), or Black (IRR 1.06, 95% CI 1.01 - 1.12), and patients being English proficient (IRR 1.08, 95% CI 1.01 - 1.15) had higher chances of subsequent glucose readings.

CONCLUSION

We found disparities in ICU glucose measurements among patients with sepsis, albeit the magnitude was small. Variation in disease monitoring is a source of data bias that may lead to spurious correlations when modeling health data.

Obstetric Racial Disparities in the Era of the ARRIVE (A Randomized Trial of Induction Versus Expectant Management) Trial and the Coronavirus Disease 2019 (COVID-19) Pandemic

OBJECTIVE

To evaluate the influence of the ARRIVE (A Randomized Trial of Induction Versus Expectant Management) trial and the coronavirus disease 2019 (COVID-19) pandemic on racial and ethnic differences in labor induction, pregnancy-associated hypertension, and cesarean delivery among non-Hispanic Black and non-Hispanic White low-risk, first-time pregnancies.

METHODS

We conducted an interrupted time series analysis of U.S. birth certificate data from maternal non-Hispanic Black and non-Hispanic White race and ethnicity, first pregnancy, 39 or more weeks of gestation, with no documented contraindication to vaginal delivery or expectant management beyond 39 weeks. We compared the rate of labor induction (primary outcome), pregnancy-associated hypertension, and cesarean delivery during three time periods: pre-ARRIVE (January 1, 2015-July 31, 2018), post-ARRIVE (November 1, 2018-February 29, 2020), and post-COVID-19 (March 1, 2020-December 31, 2021).

RESULTS

In the post-ARRIVE period, the rate of labor induction increased in both non-Hispanic White and non-Hispanic Black patients, with no statistically significant difference in the magnitude of increase between the two groups (rate ratio for race [RR race ] 0.98, 95% CI, 0.95-1.02, P =.289). Post-COVID-19, the rate of labor induction increased in non-Hispanic White but not non-Hispanic Black patients. The magnitude of the rate change between non-Hispanic White and non-Hispanic Black patients was significant (RR race 0.95, 95% CI, 0.92-0.99, P =.009). Non-Hispanic Black pregnant people were more likely to have pregnancy-associated hypertension and more often delivered by cesarean at all time periods.

CONCLUSION

Changes in obstetric practice after both the ARRIVE trial and the COVID-19 pandemic were not associated with changes in Black-White racial differences in labor induction, cesarean delivery, and pregnancy-associated hypertension.

Counselor bias and contraceptive counseling for women: a scoping review protocol

OBJECTIVE

The objective of this review is to identify factors, tools, and interventions related to counselor biases and contraceptive counseling in women.

INTRODUCTION

Contraceptive counseling is the transfer of knowledge regarding contraceptive methods to aid an individual in selecting, discontinuing, or changing contraception. The counselor should deliver information based on the patient's needs and preferences. The type and quality of the contraceptive information women are provided should not vary based on social or physical factors, such as age, race, religion, sexual orientation, education level, sexual preference, or weight; however, professional bias continues to be a concern in health care. The results of this review may further the understanding of counselor bias and contraceptive counseling.

INCLUSION CRITERIA

This scoping review will consider studies that include health care professionals providing contraceptive counseling to female patients in any setting or geographic location. Studies reporting on factors, tools, and interventions related to counselor bias and contraceptive counseling will be included.

METHODS

Databases to be searched are MEDLINE, CINAHL, Scopus, Web of Science, ScienceDirect, JBI Evidence-based Practice Database, Europe PubMed Central, and Cochrane Library. Sources of gray literature will include ProQuest Dissertations and Theses, PaperFirst, and MedNar. The review will include studies published in English from 1994 onward and follow the JBI methodology for scoping reviews. Two independent reviewers will screen the titles and abstracts, then full texts. Data from relevant studies will be extracted using a tool created by the reviewers. The results will be presented as a narrative summary and in diagrammatic or tabular format.

REVIEW REGISTRATION

Open Science Framework https://osf.io/judp5.

Blind spots in medical education - International perspectives

BACKGROUND

All individuals and groups have blind spots that can create problems if unaddressed. The goal of this study was to examine blind spots in medical education from international perspectives.

METHODS

From December 2022 to March 2023, we distributed an electronic survey through international networks of medical students, postgraduate trainees, and medical educators. Respondents named blind spots affecting their medical education system and then rated nine blind spot domains from a study of U.S. medical education along five-point Likert-type scales (1 = much less attention needed; 5 = much more attention needed). We tested for differences between blind spot ratings by respondent groups. We also analyzed the blind spots that respondents identified to determine those not previously described and performed content analysis on open-ended responses about blind spot domains.

RESULTS

There were 356 respondents from 88 countries, including 127 (44%) educators, 80 (28%) medical students, and 33 (11%) postgraduate trainees. At least 80% of respondents rated each blind spot domain as needing 'more' or 'much more' attention; the highest was 88% for 'Patient perspectives and voices that are not heard, valued, or understood.' In analyses by gender, role in medical education, World Bank country income level, and region, a mean difference of 0.5 was seen in only five of the possible 279 statistical comparisons. Of 885 blind spots documented, new blind spot areas related to issues that crossed national boundaries (e.g. international standards) and the sufficiency of resources to support medical education. Comments about the nine blind spot domains illustrated that cultural, health system, and governmental elements influenced how blind spots are manifested across different settings.

DISCUSSION

There may be general agreement throughout the world about blind spots in medical education that deserve more attention. This could establish a basis for coordinated international effort to allocate resources and tailor interventions that advance medical education.

Using a Social Model to Guide Individualized Education Program Development and Change Educational Paradigms to Be Critically Inclusive

PURPOSE

The Individuals with Disabilities Education Act explicitly acknowledges disability as a natural part of the human experience. However, special education services, including speech-language services, often focus on remediating the characteristics of the individual with the disability rather than addressing the disabling conditions of the school environment or leveraging the supports and resources available or potentially available to the student. The purpose of this article is to provide a social model of disability framework to guide Individualized Education Program (IEP) development and change educational paradigms around language and communication.

METHOD

A discussion of a new theoretical framework, critical inclusion, is situated within the speech-language pathologist's role in the IEP process. An argument for adopting an integrative approach to service delivery through the social model of disability is provided. The Social Communication and Engagement Triad framework is then used to illustrate a social model of disability approach to assessment, IEP goal development, and service delivery case examples.

CONCLUSIONS

Speech-language pathologists and all educators have a responsibility for creating a space where all learners belong and diversity in all aspects is celebrated. Embracing a social model of disability approach to the IEP process can support practitioners in their work toward creating a more equitable and inclusive education system.

Addressing Disparities in Acute Stroke Management and Prognosis

There are now abundant data demonstrating disparities in acute stroke management and prognosis; however, interventions to reduce these disparities remain limited. This special report aims to provide a critical review of the current landscape of disparities in acute stroke care and highlight opportunities to use implementation science to reduce disparities throughout the early care continuum. In the prehospital setting, stroke symptom recognition campaigns that have been successful in reducing prehospital delays used a multilevel approach to education, including mass media, culturally tailored community education, and professional education. The mobile stroke unit is an organizational intervention that has the potential to provide more equitable access to timely thrombolysis and thrombectomy treatments. In the hospital setting, interventions to address implicit biases among health care providers in acute stroke care decision-making are urgently needed as part of a multifaceted approach to advance stroke equity. Implementing stroke systems of care interventions, such as evidence-based stroke care protocols at designated stroke centers, can have a broader public health impact and may help reduce geographic, racial, and ethnic disparities in stroke care, although further research is needed. The long-term impact of disparities in acute stroke care cannot be underestimated. The consistent trend of longer time to treatment for Black and Hispanic people experiencing stroke has direct implications on long-term disability and independence after stroke. A learning health system model may help expedite the translation of evidence-based interventions into clinical practice to reduce disparities in stroke care.

"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.

Using the Social Vulnerability Index to Analyze Statewide Health Disparities in Cholecystectomy

INTRODUCTION

Addressing the effects of social determinants of health in surgery has become a national priority. We evaluated the utility of the Social Vulnerability Index (SVI) in determining the likelihood of receiving cholecystectomy for cholecystitis in Texas.

METHODS

A retrospective study of adults with cholecystitis in the Texas Hospital Inpatient Discharge Public Use Data File and Texas Outpatient Surgical and Radiological Procedure Data Public Use Data File from 2016 to 2019. Patients were stratified into SVI quartiles, with the lowest quartile as low vulnerability, the middle two as average vulnerability, and the highest as high vulnerability. The relative risk (RR) of undergoing surgery was calculated using average vulnerability as the reference category and subgroup sensitivity analyses.

RESULTS

A total of 67,548 cases were assessed, of which 48,603 (72.0%) had surgery. Compared with the average SVI groups, the low vulnerability groups were 21% more likely to undergo cholecystectomy (RR = 1.21, 95% confidence interval [CI] 1.18-1.24), whereas the high vulnerability groups were 9% less likely to undergo cholecystectomy (RR = 0.91, 95% CI 0.88-0.93). The adjusted model showed similar results (RR = 1.05, 95% CI 1.04-1.06 and RR = 0.97, 95% CI 0.96-0.99, for low and high vulnerability groups, respectively). These results remained significant after stratifying for age, sex, ethnicity, and insurance status. However, the differences between low, average, and high vulnerability groups diminished in rural settings, with lower surgery rates in all groups.

CONCLUSIONS

Patients with higher SVI were less likely to receive an elective cholecystectomy. SVI is an effective method of identifying social determinants impacting access to and receipt of surgical care.

Physician Workforce Diversity Is Still Necessary and Achievable if It Is Intentionally Prioritized

The 2023 Supreme Court Decision from Students for Fair Admissions v. Harvard and Students for Fair Admissions v. University of North Carolina threatens the current progress in achieving diversity within undergraduate and graduate medical education. This is necessary to achieve a diverse healthcare workforce, which is a key to healing historical healthcare trauma, eliminating health disparities, and providing equitable healthcare access for all communities. Although the Supreme Court decision seems obstructionist, viable opportunities exist to enhance recruitment further and solidify diversity efforts in undergraduate and graduate medical education to achieve these goals.

Utilization of Art in Nursing Education to Enhance Student Spiritual Growth and Holistic Nursing Practice

Purpose: The purpose of this study was to investigate student nurses' perceptions of how creative art activities might support spiritual self-exploration, foster understanding of holistic care and promote spiritual growth in relation to Mercy and Jesuit values emphasized in their nursing program. Design: A qualitative design was used with data collected through surveys and students' reflections. Methods: Students enrolled in an introductory nursing course with a service-learning component participated in the study. Students were initially asked to create drawings depicting Mercy/Jesuit charisms, spirituality, and holistic nursing then complete written reflections. At the term's end, students created group art projects connecting service learning, holistic nursing care, and spiritual growth. Students responded to survey questions regarding spirituality, Mercy/Jesuit charisms, nursing practice, and their art experiences. Findings: Surveys were completed by 122 of the 137 students who participated in the art projects. After initial difficulty with artistic expression, most students reported the projects provided an opportunity for introspection related to personal spirituality, nursing, and the impact of service-learning experiences on future nursing practice. Conclusion: Arts-based learning can help students explore and express spirituality related to nursing and support their understanding and integration of values essential to the delivery of holistic nursing care.

Review on clinician bias and its impact on racial and socioeconomic disparities in pediatric heart transplantation

This expert review seeks to highlight implicit bias in health care, transplant medicine, and pediatric heart transplantation to focus attention on the role these biases may play in the racial/ethnic and socioeconomic disparities noted in pediatric heart transplantation. This review breaks down the transplant decision making process to highlight points at which implicit bias may affect outcomes and discuss how the science of human decision making may help understand these complex processes.

Cultural Responsiveness in Behavior Analysis: Provider and Recipient Perceptions in Ontario

Cultural responsiveness is critical to providing high-quality behavior analytic services, particularly when providers and recipients have different cultural backgrounds. The purpose of this study was to systematically replicate and extend (Beaulieu et al. (2019) Behavior Analysis in Practice, 12(3), 557-575) by investigating the diversity among applied behavior analysis (ABA) service providers and service recipients in Ontario, service providers' training and experiences in working with diverse families, and service providers' and recipients' perceptions of behavior analysts' cultural responsiveness in practice. Results from 428 participants suggest that service providers and recipients in Ontario differ in demographic characteristics; service providers report having little training in how to serve diverse families; and although service recipients rate providers' skills relatively positively, there is room for improvement. Results suggest a path forward for behavior analysis that includes education and training in cultural responsiveness as well as encouraging and fostering a bidirectional relationship between behavior analysts and the families they serve.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40617-023-00825-w.

Examining the pedagogical practices that support cultural proficiency development in graduate health science students

BACKGROUND

Health disparities are often a function of systemic discrimination and healthcare providers' biases. In recognition of this, health science programs have begun to offer training to foster cultural proficiency (CP) in future professionals. However, there is not yet consensus about the best ways to integrate CP into didactic and clinical education, and little is known about the role of clinical rotations in fostering CP.

METHODS

Here, a mixed-methods approach was used to survey students (n = 131) from a private all-graduate level osteopathic health sciences university to gain insight into the training approaches students encountered related to CP and how these may vary as a function of academic progression. The research survey included instruments designed to quantify students' implicit associations, beliefs, and experiences related to the CP training they encountered through the use of validated instruments, including Implicit Association Tests and the Ethnocultural Empathy Inventory, and custom-designed questions.

RESULTS

The data revealed that most students (73%) had received CP training during graduate school which primarily occurred via discussions, lectures, and readings; however, the duration and students' perception of the training varied substantially (e.g., training range = 1-100 hours). In addition, while students largely indicated that they valued CP and sought to provide empathetic care to their patients, they also expressed personal understandings of CP that often fell short of advocacy and addressing personal and societal biases. The results further suggested that clinical rotations may help students attenuate implicit biases but did not appear to be synergistic with pre-clinical courses in fostering other CP knowledge, skills, and attitudes.

CONCLUSIONS

These findings highlight the need to utilize evidence-based pedagogical practices to design intentional, integrated, and holistic CP training throughout health science programs that employ an intersectional lens and empowers learners to serve as advocates for their patients and address systemic challenges.

People who living with HIV/AIDS also have a high prevalence of anxiety disorders: a systematic review and meta-analysis

Background

An estimated 301 million people worldwide suffer from anxiety disorders. People living with HIV/AIDS (PLWHA) are particularly prone to anxiety disorders that could interfere with the important developmental process in an individual's development and ultimately result in a wide range of negative mental, physical, and psychosocial consequences, as well as poor quality of life in those population groups. Early intervention for anxiety disorders can reverse some of the physical damage caused by anxiety. However, based on systematic reviews and meta-analyses, the specific prevalence of anxiety disorders in PLWHA remains unknown.

Method

We conducted a literature search on PubMed, Embase, and Web of Science up to 22 October 2022. A random-effects meta-analysis was used to pool prevalence rates from the included studies. Sensitivity and subgroup analyses were performed to identify the possible sources of heterogeneity and to compare the prevalence estimates across groups. The Joanna Briggs Institute's Quality Assessment Checklist was used to assess the quality of the included studies. Cochran's Q and I2 tests were used to assess the between-study heterogeneity.

Results

Ten studies with a total of 238,570 cases were included for the final analysis. Results showed that 15.5% of HIV/AIDS patients had anxiety disorders. The prevalence was higher in females (20.8%) than males (20.7%). The mean age of PLWHA with anxiety disorders was 46.58 ± 11.15 years in these included studies. The subgroup analyses showed significant higher prevalence in non-heterosexual (32.1%).

Conclusion

We attempted to quantify literature that could allow for stronger inferences to be made regarding the significantly higher prevalence of anxiety disorders in PLWHA, a finding that suggests the imperativeness of intervention strategies to alleviate suffering and reduce the probable negative ramifications.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023442219, identifier CRD42023442219.