Addressing microaggressions in racially charged patient-provider interactions: a pilot randomized trial

Microaggressions and Cultural Ruptures in Psychiatry: Extending Multicultural Counseling Orientation to Psychiatric Services

Racial microaggressions and cultural ruptures have a significant impact on mental health care for Black, Indigenous, and people of color (BIPOC) communities. This article reviews the application of the multicultural counseling orientation framework in psychiatry to address these challenges and improve therapeutic outcomes. The authors outline strategies to integrate cultural humility into psychiatric practice, with an emphasis on self-reflection, feedback, and the recognition of microaggressions. By fostering cultural humility, providers can create therapeutic spaces where patients feel safe and validated. The article also discusses cultural opportunities for exploring patients' identities and advocates for open dialogue that addresses these aspects early in treatment. Structural recommendations include enhancing training programs to incorporate equity-focused coursework, promoting recruitment and retention of BIPOC clinicians, and developing institutional policies to address systemic inequities. Adopting these approaches can reduce the adverse effects of microaggressions, build trust, and improve mental health outcomes for BIPOC patients. The authors suggest that future efforts should emphasize systemic changes in training, recruitment, and community engagement to create a more inclusive mental health care system.

Patient at community clinics: Recommendations for advancing health literacy

OBJECTIVE

This study aimed to assess community clinics in enhancing health literacy among underserved patients. We focus on patient-provider communication at these clinics to understand how this communication may foster or hinder health literacy and how the organizational health literacy of clinics may be improved.

METHODS

We surveyed 303 patients at three community clinics to evaluate providers' communication behaviors related to health literacy. The city health department entered surveys into SurveyMonkey™ and analyzed them using Stata/SE™. The analysis included frequencies of all variables for all participants and by clinic. Qualitative methods were also used.

RESULTS

Community clinics are trusted care sources; however, around 13 % of patients reported rarely or never being encouraged to ask questions, 20 % reported providers spoke too fast, and 17 % reported that medical staff were not always informative. Patients needing an interpreter reported more communication problems than those not requiring one, making these results more salient.

CONCLUSIONS

Community clinics serving low-income patients can enhance personal and organizational health literacy by improving patient-provider communication such as active listening, encouraging patients to ask questions, and addressing language barriers.

PRACTICE IMPLICATIONS

Advancing health literacy impacts community and public health initiatives, improves health disparities, builds patient-provider trust, and improves health systems.

Does Mindfulness Improve Intergroup Bias, Internalized Bias, and Anti-Bias Outcomes?: A Meta-Analysis of the Evidence and Agenda for Future Research

Whereas mindfulness has been shown to enhance personal well-being, studies suggest it may also benefit intergroup dynamics. Using an integrative conceptual model, this meta-analysis examined associations between mindfulness and (a) different manifestations of bias (implicit/explicit attitudes, affect, behavior) directed toward (b) different bias targets (outgroup or ingroup, e.g., internalized bias), by (c) intergroup orientation (toward bias or anti-bias). Of 70 samples, 42 (N = 3,229) assessed mindfulness-based interventions (MBIs) and 30 (N = 6,002) were correlational studies. Results showed a medium-sized negative effect of MBIs on bias outcomes, g = -0.56, 95% confidence interval [-0.72, -0.40]; I(2;3)2: 0.39; 0.48, and a small-to-medium negative effect between mindfulness and bias for correlational studies, r = -0.17 [-0.27, -0.03]; I(2;3)2: 0.11; 0.83. Effects were comparable for intergroup bias and internalized bias. We conclude by identifying gaps in the evidence base to guide future research.

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.

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.

Black veteran use of video telehealth for mental health care

Black veterans experience disparities in mental health (MH) care access and are disproportionately affected by COVID-19. Video telehealth to home (VTH) may reduce disparities by addressing barriers, particularly with pandemic-related shifts to remotely delivered care. Considering potential needs for tailored implementation across racial/ethnic groups, we examined differences in VTH use by non-Hispanic Black veterans versus all other races/ethnicities and among Black (Hispanic and non-Hispanic) veterans by age, rurality, and gender during the pandemic. We extracted a cohort of Veterans Health Administration-enrolled veterans receiving at least one MH encounter between October 2019 and September 2020 (n = 1,627,791) from electronic health records. Multilevel linear growth curve models examined the percentage of VTH use for non-Hispanic Black versus other races/ethnicities before and after pandemic onset. Black veteran-only subgroup analyses examined differences by ethnicity in percentage of VTH MH encounters since pandemic onset by age, rurality, and gender, using regression and analysis of covariance models. Despite significant increases in VTH during the pandemic, on average, VTH use was consistently lower for non-Hispanic Black veterans across both periods. During the pandemic, differences in VTH use between non-Hispanic Black and non-Black veterans accelerated over time. VTH use was greater during the pandemic for Black veterans who were Hispanic, younger, urban, and female. Adoption of VTH for MH was low for non-Hispanic Black veterans before COVID-19 and during COVID-19 compared to non-Black groups. Future VTH research and implementation efforts should question why adoption remains low, work to meet cultural needs, and promote equitable adoption for Black veterans. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Exploring The Impact of Acceptance and Commitment Based Cultural Humility Training on Standardized Patient Interactions: Revisiting the Measurement Process

Recent findings in health sciences and medical education highlight the importance of training healthcare professionals to interact with their patients in a culturally humble manner (Nadal et al., in Journal of Counseling and Development 92: 57-66, 2014; Pascoe & Smart Richman, in Psychological Bulletin 135: 531, 2009; Sirois & Burg, in Behavior Modification 27: 83-102, 2003; Williams & Mohammed, in Journal of Behavioral Medicine 32: 20-47, 2009). An important piece in the progression of our ability to address training challenges is the assessment of cultural humility. As an extension of previous research (Lombardero et al., in Journal of Clinical Psychology in Medical Settings, 30: 261-273, 2023), this study implemented an evidence-based cultural humility intervention (based on Acceptance and Commitment Training) to improve medical students' interactions with standardized patients (SPs) which was assessed via direct behavioral observation. Specifically, the observational measurement system was focused on culturally humble responses to patients reporting microaggressions to the medical professional. A pre-post comparison of the results demonstrated statistically significant improvements pertaining to participants' culturally humble responses to SPs' reports of microaggressions for one of the measurement scales used (i.e., ARISE), but not the other (i.e., Responsiveness to Racial Challenges Scale). Further analyses, on the bottom quartile of performers, were conducted to assess a possible ceiling effect of the scale that did not demonstrate significant change. These results and implications for future research will be discussed.

Diabetes distress in urban Black youth with type 1 diabetes and their caregivers: associations with glycemic control, depression, and health behaviors

OBJECTIVES

Adolescents with type 1 diabetes (T1D) and their caregivers endorse high diabetes distress (DD). Limited studies have documented the impact of DD on Black youth. The aims of the present study were to (1) describe DD among a sample of Black adolescents with T1D and their caregivers, (2) compare their DD levels with published normative samples, and (3) determine how DD relates to glycemic outcomes, diabetes self-management, parental monitoring of diabetes, and youth depressive symptoms.

METHODS

Baseline data from a multicenter clinical trial were used. Participants (N = 155) were recruited from 7 Midwestern pediatric diabetes clinics. Hemoglobin A1c (HbA1c) and measures of DD, parental monitoring of diabetes care, youth depression and diabetes management behaviors were obtained. The sample was split into (1) adolescents (ages 13-14; N = 95) and (2) preadolescents (ages 10-12; N = 60). Analyses utilized Cohen's d effect sizes, Pearson correlations, t-tests, and multiple regression.

RESULTS

DD levels in youth and caregivers were high, with 45%-58% exceeding either clinical cutoff scores or validation study sample means. Higher DD in youth and caregivers was associated with higher HbA1c, lower diabetes self-management, and elevated depressive symptoms, but not with parental monitoring of diabetes management.

CONCLUSIONS

Screening for DD in Black youth with T1D and caregivers is recommended, as are culturally informed interventions that can reduce distress levels and lead to improved health outcomes. More research is needed on how systemic inequities contribute to higher DD in Black youth and the strategies/policy changes needed to reduce these inequities.

Designing Communication Feedback Systems To Reduce Healthcare Providers' Implicit Biases In Patient Encounters

Healthcare providers' implicit bias, based on patients' physical characteristics and perceived identities, negatively impacts healthcare access, care quality, and outcomes. Feedback tools are needed to help providers identify and learn from their biases. To incorporate providers' perspectives on the most effective ways to present such feedback, we conducted semi-structured design critique sessions with 24 primary care providers. We found that providers seek feedback designed with transparent metrics indicating the quality of their communication with a patient and trends in communication patterns across visits. Based on these metrics and trends, providers want this feedback presented in a dashboard paired with actionable, personalized tips about how to improve their communication behaviors. Our study provides new insights for interactive systems to help mitigate the impact of implicit biases in patient-provider communication. New systems that build upon these insights could support providers in making healthcare more equitable, particularly for patients from marginalized communities.

ConverSense: An Automated Approach to Assess Patient-Provider Interactions using Social Signals

Patient-provider communication influences patient health outcomes, and analyzing such communication could help providers identify opportunities for improvement, leading to better care. Interpersonal communication can be assessed through "social-signals" expressed in non-verbal, vocal behaviors like interruptions, turn-taking, and pitch. To automate this assessment, we introduce a machine-learning pipeline that ingests audio-streams of conversations and tracks the magnitude of four social-signals: dominance, interactivity, engagement, and warmth. This pipeline is embedded into ConverSense, a web-application for providers to visualize their communication patterns, both within and across visits. Our user study with 5 clinicians and 10 patient visits demonstrates ConverSense's potential to provide feedback on communication challenges, as well as the need for this feedback to be contextualized within the specific underlying visit and patient interaction. Through this novel approach that uses data-driven self-reflection, ConverSense can help providers improve their communication with patients to deliver improved quality of care.

Leveraging Resident-As-Teacher Training for Health Equity Education: A Transformative Approach

Issue: Resident teachers play an essential role in medical education and can support broader efforts to advance anti-racism and health equity in medicine. The Accreditation Council for Graduate Medical Education requires programs to provide education about health care disparities so residents can contribute to and lead work in this area. However, the literature includes few examples, frameworks, or strategies for preparing residents to develop the knowledge and skills needed to promote health equity, including in their role as clinical teachers. Evidence: In this article, the authors propose leveraging Resident-as-Teacher training to support residents in learning and teaching for health equity. Gorski's conceptualization of equity literacy provides an evidence-based framework for four main abilities (recognizing, responding, redressing, and cultivating/sustaining) residents and medical students can develop through co-learning about health equity in the clinical learning environment. The authors discuss preconditions, example activities, and assessments strategies for effective health equity education. Based on the principles of social learning theory, the authors recommend that Resident-as-Teacher training be part of an institutional strategy to cultivate a community of practice for health equity education. Implications: Incorporating health equity education into Resident-as-Teacher curriculum offers a potentially transformative part of the broader strategy needed to prepare the next generation of physicians to enact anti-racism and advance health equity.

Antiracist training programs for mental health professionals: A scoping review

Racism has been shown to be directly deleterious to the mental health care received by minoritized peoples. In response, some mental health institutions have pledged to provide antiracist mental health care, which includes training mental health care professionals in this approach. This scoping review aimed to synthesize the existing published material on antiracist training programs among mental health care professionals. To identify studies, a comprehensive search strategy was developed and executed by a research librarian in October 2022 across seven databases (APA PsycInfo, Education Source, Embase, ERIC, MEDLINE, CINAHL, and Web of Science). Subject headings and keywords relating to antiracist training as well as to mental health professionals were used and combined. There were 7186 studies generated by the initial search and 377 by the update search, 30 were retained and included. Findings revealed four main antiracist competencies to develop in mental health professionals: importance of understanding the cultural, social, and historical context at the root of the mental health problems; developing awareness of individual biases, self-identity and privilege; recognizing oppressive and racism-sustaining behaviors in mental health care settings; and, employing antiracist competencies in therapy. Professionals who have taken trainings having the main components have developed skills on the interconnectedness between racialized groups' mental health and the cultural, religious, social, historical, economic, and political issues surrounding race, necessary for successful clinical practice and for providing anti-racist mental health care. This scoping review presents a summary of the essential antiracist competencies drawn from the literature which must be applied in a mental health care setting, to improve help seeking behaviors, and reduce distrust in mental health care professionals and settings.

Impact of Social Vulnerability on Diabetes-Related Cardiovascular Mortality in the United States

Background Social vulnerability impacts the natural history of diabetes as well as cardiovascular disease (CVD). However, there are little data regarding the social vulnerability association with diabetes-related CVD mortality. Methods and Results County-level mortality data (where CVD was the underlying cause of death with diabetes among the multiple causes) extracted from the Centers for Disease Control multiple cause of death (2015-2019) and the 2018 Social Vulnerability Index databases were aggregated into quartiles based on their Social Vulnerability Index ranking from the least (first quartile) to the most vulnerable (fourth quartile). Stratified by demographic groups, the data were analyzed for overall CVD, as well as for ischemic heart disease, hypertensive disease, heart failure, and cerebrovascular disease. In the 5-year study period, 387 139 crude diabetes-related cardiovascular mortality records were identified. The age-adjusted mortality rate for CVD was higher in the fourth quartile compared with the first quartile (relative risk [RR], 1.66 [95% CI, 1.64-1.67]) with an estimated 39 328 excess deaths. Among the youngest age group (<55 years), those with the highest social vulnerability had 2 to 4 times the rate of cardiovascular mortality compared with the first quartile: ischemic heart disease (RR, 2.07 [95% CI, 1.97-2.17]; heart failure (RR, 3.03 [95% CI, 2.62-3.52]); hypertensive disease (RR, 3.79 [95% CI, 3.45-4.17]; and cerebrovascular disease (RR, 4.39 [95% CI, 3.75-5.13]). Conclusions Counties with greater social vulnerability had higher diabetes-related CVD mortality, especially among younger adults. Targeted health policies that are designed to reduce these disparities are warranted.

Perceptions of healthcare professionals and students about interventions addressing implicit bias and microaggression: A mixed-studies systematic review

AIM

To consolidate and appraise available evidence on the experiences and perceptions of healthcare professionals and students about the interventions addressing implicit bias and microaggression in the clinical setting.

BACKGROUND

Patient-perpetrated acts of implicit bias and microaggression have profound effects on healthcare professionals' and students' mental health. However, the efficacy of interventions targeted at addressing implicit bias and microaggression requires further scrutiny.

DESIGN

Mixed-studies systematic review.

METHODS

A comprehensive search was conducted on PubMed, EMBASE, CINAHL, Scopus, Web of Science, PsycINFO, Cochrane Library, ProQuest (Social Science Premium Collection Database), ProQuest (Dissertations and Theses Global), and ClinicalTrials.gov. Study selection, quality appraisal using the mixed methods appraisal tool, and data extraction were performed. Narrative and thematic synthesis were used to analyze quantitative and qualitative findings respectively. A results-based convergent approach was employed to integrate findings from both research designs.

RESULTS

A total of 23 studies were included, involving 4667 healthcare professionals and students. There were 17 quantitative studies and six mixed-method studies of varying methodological quality. This review presented findings on healthcare professionals' and students' experiences and perceptions of the efficacy of the interventions targeted at addressing implicit bias and microaggression. Two themes were identified: 1) A safe space leading to enhanced confidence, and 2) what and why the interventions worked.

CONCLUSION

Our review findings found that healthcare professionals and students generally had a positive view of implicit bias and microaggression interventions in the realm of helping them gain knowledge and confidence to identify and respond to biased clinical encounters. This review could provide insights for administrators and institutions to provide such interventions in mitigating the impact of implicit bias and microaggression on healthcare staff and students. Future research should focus on comparing the views of participants from varied geographical and cultural backgrounds, and those with different healthcare disciplines.

The illusion of inclusion: contextual behavioral science and the Black community

Anti-racism approaches require an honest examination of cause, impact, and committed action to change, despite discomfort and without experiential avoidance. While contextual behavioral science (CBS) and third wave cognitive-behavioral modalities demonstrate efficacy among samples composed of primarily White individuals, data regarding their efficacy with people of color, and Black Americans in particular, is lacking. It is important to consider the possible effects of racial stress and trauma on Black clients, and to tailor approaches and techniques grounded in CBS accordingly. We describe how CBS has not done enough to address the needs of Black American communities, using Acceptance and Commitment Therapy (ACT) and Functional Analytic Psychotherapy (FAP) as examples. We also provide examples at the level of research representation, organizational practices, and personal experiences to illuminate covert racist policy tools that maintain inequities. Towards eradicating existing racism in the field, we conclude with suggestions for researchers and leadership in professional psychological organizations.

Implicit Bias and Patient Care: Mitigating Bias, Preventing Harm

Introduction

Simulation is a valuable and novel tool in the expanding approach to racism and bias education for medical practitioners. We present a simulation case focused on identifying and addressing the implicit bias of a consultant to teach bias mitigation skills and limit harm to patients and families.

Methods

Learners were presented with a case of a classic toddler's fracture in an African American child. The learners interacted with an orthopedic resident who insisted on child welfare involvement, with nonspecific and increasingly biased concerns about the child/family. The learners were expected to identify that this case was not concerning for nonaccidental trauma and that the orthopedic resident was demonstrating bias. They were expected to communicate with both the resident and the parent effectively to defuse the situation and prevent harm from reaching the family. A debrief and an anonymous survey followed the case.

Results

Seventy-five learners participated, including pediatric and emergency medicine residents, fellows, attendings, and medical students. After the case, the majority of learners expressed confidence that they could recognize racial bias in the care of a patient (90%), ensure patient care was not influenced by racial bias (88%), and utilize a tool to frame a concern about bias (79%).

Discussion

Participants felt that this simulation was relevant and effective and overall left the experience feeling confident in their abilities to identify and manage racially biased patient care. This anti-racist simulation offers an important skill-building opportunity that has been well received by learners.

A scoping review of emotions and related constructs in simulation-based education research articles

BACKGROUND

While acknowledgement of emotions' importance in simulation-based education is emerging, there are concerns regarding how education researchers understand the concept of emotions for them to deliberately incorporate emotionally charged scenarios into simulation-based education. This concern is highlighted especially in the context of medical education often lacking strong theoretical integration. To map out how current simulation-based education literature conceptualises emotion, we conducted a scoping review on how emotions and closely related constructs (e.g. stress, and emotional intelligence) are conceptualised in simulation-based education articles that feature medical students, residents, and fellows.

METHODS

The scoping review was based on articles published in the last decade identified through database searches (EMBASE and Medline) and hand-searched articles. Data extraction included the constructs featured in the articles, their definitions, instruments used, and the types of emotions captured. Only empirical articles were included (e.g. no review or opinion articles). Data were charted via descriptive analyses.

RESULTS

A total of 141 articles were reviewed. Stress was featured in 88 of the articles, while emotions and emotional intelligence were highlighted in 45 and 34 articles respectively. Conceptualisations of emotions lacked integration of theory. Measurements of emotions mostly relied on self-reports while stress was often measured via physiological and self-report measurements. Negative emotions such as anxiety were sometimes seen as interchangeable with the term stress. No inferences were made about specific emotions of participants from their emotional intelligence.

CONCLUSIONS

Our scoping review illustrates that learners in simulation-based education are most often anxious and fearful. However, this is partially due to medical education prioritising measuring negative emotions. Further theoretical integration when examining emotions and stress may help broaden the scope towards other kinds of emotions and better conceptualisations of their impact. We call for simulation education researchers to reflect on how they understand emotions, and whether their understanding may neglect any specific aspect of affective experiences their simulation participants may have.

Promoting appetitive learning of consensual, empowered vulnerability: a contextual behavioral conceptualization of intimacy

Vulnerability is emphasized in a number of theoretical models of intimacy (e.g., Intimacy Process Model), including from behavioral and contextual behavioral perspectives. Vulnerability is generally defined as susceptibility to harm and involves behaviors that have been historically met with aversive social consequences. From these perspectives, intimacy is fostered when vulnerable behavior is met with reinforcement. For example, interventions have trained intimacy by building skills in emotional expression and responsiveness with promising results. Vulnerability has divergent functions, however, depending on the interpersonal context in which it occurs. Functional intimacy is explored through the lens of functional relations, which play a key role in interpersonal processes of power, privilege, and consent. This conceptualization suggests that vulnerability must be under appetitive functional relations, consensual, and empowered for safe intimacy to emerge. The responsibility to promote appetitive learning of consensual, empowered vulnerability to foster intimacy falls to the person with more power in a particular interaction and relationship. Recommendations are offered for guiding this process.

Training Student Pharmacists How to Mitigate Racial or Ethnic Microaggressions in Patient Encounters

The experience of interfacing with the health care system is a taxing one for racially or ethnically marginalized patients (REMPs). The seemingly inevitable occurrence of encountering microaggressions is reason enough to avoid the interaction for many resulting in worse health outcomes. Microaggressions result in conflict, loss to follow-up, and reinforcing the unwelcome atmosphere of the health care system to REMPs. Teaching antimicroaggressive content in doctor of pharmacy curricula is critical for reducing strain on the fragile relationship between REMPs and the health care system. Whether it is gathering a patient history, devising a patient-centered care plan, or counseling patients, there is an opportunity for an interaction that could sever the patient's trust in the health care system. Teaching each of these skills-based learning activities should be combined with didactic lessons in nonjudgmental and nonmicroaggressive communication approaches. In addition, lessons regarding the impact of microaggressions on REMPs should also be present so that learners may appreciate the impact of a clinician's actions on REMPs in this regard. To establish evidence-based best practices, more research on teaching antimicroaggressive didactic and skills-based content to student pharmacists is needed.

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

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

The Presence 5 for Racial Justice Framework for anti-racist communication with Black patients

OBJECTIVE

To identify communication practices that clinicians can use to address racism faced by Black patients, build trusting relationships, and empower Black individuals in clinical care.

DATA SOURCES

Qualitative data (N = 112 participants, August 2020-March 2021) collected in partnership with clinics primarily serving Black patients in Leeds, AL; Memphis, TN; Oakland, CA; and Rochester, NY.

STUDY DESIGN

This multi-phased project was informed by human-centered design thinking and community-based participatory research principles. We mapped emergent communication and trust-building strategies to domains from the Presence 5 framework for fostering meaningful connection in clinical care.

DATA COLLECTION METHODS

Interviews and focus group discussions explored anti-racist communication and patient-clinician trust (n = 36 Black patients; n = 40 nonmedical professionals; and n = 24 clinicians of various races and ethnicities). The Presence 5 Virtual National Community Advisory Board guided analysis interpretation.

PRINCIPAL FINDINGS

The emergent Presence 5 for Racial Justice (P5RJ) practices include: (1) Prepare with intention by reflecting on identity, bias, and power dynamics; and creating structures to address bias and structural determinants of health; (2) Listen intently and completely without interruption and listen deeply for the potential impact of anti-Black racism on patient health and interactions with health care; (3) Agree on what matters most by having explicit conversations about patient goals, treatment comfort and consent, and referral planning; (4) Connect with the patient's story, acknowledging socioeconomic factors influencing patient health and focusing on positive efforts; (5) Explore emotional cues by noticing and naming patient emotions, and considering how experiences with racism might influence emotions.

CONCLUSION

P5RJ provides a framework with actionable communication practices to address pervasive racism experienced by Black patients. Effective implementation necessitates clinician self-reflection, personal commitment, and institutional support that offers time and resources to elicit a patient's story and to address patient needs.

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

Background

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

Objective

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

Design

Integrative review.

Methods

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

Results

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

Conclusions

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

An Acceptance and Commitment Training (ACT) Framework for Teaching Cultural Humility: A Guide for Translating ACT from a Therapeutic Context into a Medical Education Curriculum

The objective of this project was to train future physicians to work effectively and thoughtfully with diverse populations by teaching them to employ Acceptance and Commitment Training (ACT) skills to increase cultural humility, with the goal of improving attitudes, knowledge, and beliefs about working with diverse patients. We developed ACT for cultural humility online interactive modules as part of an elective course to teach Medical Spanish to 4th-year medical students. Pre- and post-pilot data pertaining to the cultural humility training modules on the Work-Related Acceptance and Action questionnaire, Multidimensional Cultural Humility Scale, knowledge, attitudes, and beliefs were analyzed using paired samples t-tests and Wilcoxon signed-rank tests. We also included descriptive data pertaining to overall satisfaction with the cultural humility modules and intent to apply the material learned to patient care. Our data showed a significant increase in the cultural humility of our participants as well as an increase in psychological flexibility, a higher favorability rating toward various ethnicities, improvements in attitude, and positive changes in beliefs and knowledge following completion of the modules. The modules were well received by the medical students, with high social validity ratings. The ACT for cultural humility curriculum has great potential to enhance medical education in diversity, equity, and inclusion by increasing both the understanding and the cultural humility of medical students and future professionals to work with diverse populations. The current paper provides a framework that can be used by other programs to shape the education of the future medical workforce to help promote culturally humble care.

Bias and discrimination in surgery: Where are we and what can we do about it?

Bias is an inclination or preconceived outlook that favors toward or against an idea, person, or group. It manifests in implicit and explicit ways throughout all aspects and institutions of society. These cognitive shortcuts are often based on stereotypes and can lead to prejudice and discrimination in medicine as they mediate interactions with patients, between providers, and at the institutional level. It is important to understand the drivers and consequences of bias in order to overcome barriers to representation, equity, and inclusion. This paper provides definitions of bias; discusses its manifestations across academic medicine at the institutional and individual levels; and concludes by examining techniques to reduce bias and measure progress. Equity for patients, families, and members of the broader surgical community cannot be achieved without reducing bias and discrimination. We call for action to increase intentional efforts that reduce the influences of bias in healthcare, research, and education, particularly in the field of pediatric surgery.

Managing Challenging Patient Interactions in Breast Imaging

Managing challenging patient interactions can be a daily stressor for breast imaging radiologists, leading to burnout. This article offers communication and behavioral practices for radiologists that help reduce radiologists' stress during these encounters. Patient scenarios viewed as difficult can vary among radiologists. Radiologists' awareness of their own physical, mental, and emotional states, along with skillful communications, can be cultivated to navigate these interactions and enhance resiliency. Understanding underlying causes of patients' emotional reactions, denial, and anger helps foster empathy and compassion during discussions. When exposed to extremely disruptive, angry, or racially abusive patients, having pre-existing institutional policies to address these behaviors helps direct appropriate responses and guide subsequent actions. These extreme behaviors may catch breast imaging radiologists off guard yet have potentially significant consequences. Rehearsing scripted responses before encounters can help breast imaging radiologists maintain composure in the moment, responding in a calm, nonjudgmental manner, and most effectively contributing to service recovery. However, when challenging patient encounters do trigger difficult emotions in breast imaging radiologists, debriefing with colleagues afterwards and naming the emotion can help the radiologists process their feelings to regain focus for performing clinical duties.

Understanding undergraduate students’ eHealth usage and views of the patient-provider relationship

eHealth has grown exponentially alongside technology and has become widely accessed by some populations, but little is documented about how undergraduate students use eHealth or perceive their eHealth literacy. As access to online information and non-traditional options for interacting with providers has increased, patient views of the provider-patient relationship may also be changing. This study evaluates how frequently undergraduates use eHealth, how they perceive their ability to use eHealth appropriately, and how they view their patient-provider relationships. A mixed methods approach was used to address the research questions, with quantitative data from a survey and qualitative data from follow-up interviews of twelve of the survey respondents. The survey was distributed to over 650 undergraduate students in introductory biology laboratory courses for students of all fields of interest at one university. Based on 527 survey responses and 12 interviews, students reported commonly using eHealth but being skeptical of telehealth appointments. Although students generally felt capable of finding and interpreting eHealth sources, they were not strongly confident in their ability to do so. Use of eHealth was not seen as altering the patient-provider relationship, but students expressed a desire for their physician to act more as a counselor or advisor than a guardian. Students from minority populations were more likely to use eHealth in comparison to their peers. In addition, student comfort with their provider differed by race and ethnicity, as well as whether they shared the same gender identity as their provider. This research highlights how undergraduate students, who are often making medical decisions for themselves for the first time as adults, access health information and view the patient-provider relationship differently than the traditional guardian or paternalistic model. In addition, having diverse, culturally competent medical providers are critical for students to develop the relationship with their provider that they desire.

Call to Action: Recommendations for Justice-Based Treatment of Obsessive-Compulsive Disorder With Sexual Orientation and Gender Themes

Gender and sexual minorities are subjected to minority stress in the form of discrimination and violence that leads to vigilance; identity concealment and discomfort; and internalized homophobia, biphobia, and transphobia. These experiences are related to increased susceptibility to mental health concerns in this population. Historically, the behavioral treatment of sexual orientation (SO) and gender-themed obsessive-compulsive disorder (OCD) has inadvertently reinforced anti-lesbian, gay, bisexual, transgender, queer/questioning (LGBTQ+) stigma and contributed to minority stress in clients, treatment providers, and society at large. We present updated recommendations for treatment of SO- and gender-themed OCD through a more equitable, justice-based lens, primarily through eliminating exposures that contribute to minority stress and replacing them with psychoeducation about LGBTQ+ identities, and exposures to neutral and positive stimuli, uncertainty, and core fears. We also present recommendations for equitable research on SO- and gender-themed OCD.

A Systematic Review of Assessment Tools Measuring Cultural Competence Outcomes Relevant to Pharmacy Education

Objective. To identify and describe validated assessment tools that measure cultural competence and are relevant to pharmacy education.Methods. A systematic approach was used to identify quantitative cultural competence assessment tools relevant to pharmacy education. A systematic search of the literature was conducted using the OVID and EBSCO databases and a manual search of journals deemed likely to include tools relevant to pharmacy education. To be eligible for the review, the tools had to be developed using a study sample from the United States, have at least one peer-reviewed validated publication, be applicable to the pharmacy profession, and be published since 2010.Results. The systematic literature and manual search identified 27 tools. Twelve assessment tools met the criteria to be included in the summary and their relevancy to pharmacy education is discussed.Conclusion. A review of literature demonstrates that assessment tools vary widely and there is no one tool that can effectively assess all aspects of cultural competence in pharmacy students or the Doctor of Pharmacy curriculum. As cultural competence is a priority within the accreditation standards for pharmacy education, PharmD programs are encouraged to develop additional tools that measure observed performance.

Frontline yet at the back of the queue – improving access and adaptations to CBT for Black African and Caribbean communities

This paper focuses on the Black minority ethnic population (Black British, Black African, Black Caribbean) and uses the term BME in reference to this group. Only 6.2% of BME people access psychological intervention for common mental disorders. In provision of cognitive behavioural therapy (CBT) the diversity in global majority populations1 requires culturally specific informed and responsive approaches. The Improving Access to Psychological Therapies (IAPT) programme needs to be accountable, culturally congruent and strategic, to ensure accessibility and improve outcomes for BME people. According to the Mental Health Foundation (2019), a higher percentage of Black, Asian and other minority ethnic populations (BAME) are diagnosed with common, severe and complex mental health disorders. Despite the weight of literature on this, little has changed. The NHS Implementation Plan outlines trajectories for increased access and reduced attrition within mental health services, addressing inequalities for BAME populations.

Evidence-based guidance and audits for provision of culturally sensitive and adapted therapies are presented in the pioneering (IAPT) BAME Positive Practice Guide (PPG). However, there are no funding arrangements or formal integrated frameworks to support implementation. The COVID-19 global pandemic and the high-profile death of George Floyd tragically exposed and highlighted the consequences of systemic racism. Understanding of the importance of service and clinical anti-racist practice is imperative for CBT therapists. Implementation of the BAME PPG audit tool ensures review of race equity in access, engagement, adaptation and workforce within IAPT and other mental health services. This could transform lives.

Key learning aims

(1)

We are part of the problem: the role of children's hospitals in addressing health inequity

Racism is an ongoing public health crisis that undermines health equity for all children in hospitals across our nation. The presence and impact of institutionalized racism contributes to health inequity and is under described in the medical literature. In this review, we focus on key interdependent areas to foster inclusion, diversity, and equity in Children's Hospitals, including 1) promotion of workforce diversity 2) provision of anti-racist, equitable hospital patient care, and 3) prioritization of academic scholarship focused on health equity research, quality improvement, medical education, and advocacy. We discuss the implications for clinical and academic practice.Plain Language Summary: Racism in Children's Hospitals harms children. We as health-care providers and hospital systems are part of the problem. We reviewed the literature for the best ways to foster inclusion, diversity, and equity in hospitals. Hospitals can be leaders in improving child health equity by supporting a more diverse workforce, providing anti-racist patient care, and prioritizing health equity scholarship.

Racial and Ethnic Disparities in the Investigation and Treatment of Growth Hormone Deficiency

OBJECTIVE

To determine if the racial/ethnic inequity in growth hormone (GH) use is due to differences in GH stimulation testing and/or prescribing patterns in children referred for endocrine evaluation of short stature.

STUDY DESIGN

Retrospective chart review was performed including children aged 2-16 years, height z-score of ≤-1.5, and of non-Hispanic White (NHW), non-Hispanic Black (NHB), or Hispanic race/ethnicity, referred for endocrine growth evaluation between January 2012 and December 2019.

RESULTS

This study included 7425 children (5905 NHW, 800 NHB, and 720 Hispanic). GH stimulation testing was performed in 992, and 576 were prescribed GH. NHW children were 1.4 (95% CI, 1.04-1.8) times more likely than NHB children and 1.7 (95% CI, 1.2-2.2) times more likely than Hispanic children to undergo GH stimulation testing. GH-treated NHB children had (1) a lower median peak GH concentration when compared with NHW (P = .02) and Hispanic (P = .08) children (NHB 4.7 ng/mL [95% CI, 1.2-8.3 ng/mL] ng/mL, NHW 7.2 ng/mL [95% CI, 4.9-9.7 ng/mL], Hispanic 7.1 ng/mL [95% CI, 4.3-11.9 ng/mL]); (2) lower median height z-scores than NHW (P = .01) but not Hispanic children (P = .5); and (3) a greater height deficit from midparental height when compared with NHW (P = .01) and Hispanic (P = .002) children.

CONCLUSIONS

Racial and ethnic disparities exist in the evaluation and treatment of children with disordered growth. This likely results from both overinvestigation of NHW children as well as underinvestigation and undertreatment of children from minority communities. The evaluation and treatment of children with short stature should be determined by clinical concern alone, but this is not current practice.

Racial Microaggressions: Critical Questions, State of the Science, and New Directions

Racial microaggressions are an insidious form of racism with devastating mental-health outcomes, but the concept has not been embraced by all scholars. This article provides an overview of new scholarship on racial microaggressions from an array of diverse scholars in psychology, education, and philosophy, with a focus on new ways to define, conceptualize, and categorize racial microaggressions. Racism, along with its many forms and manifestations, is defined and clarified, drawing attention to the linkages between racial microaggressions and systemic racism. Importantly, the developmental entry points leading to the inception of racial bias in children are discussed. Theoretical issues are explored, including the measurement of intersectional microaggressions and the power dynamics underpinning arguments designed to discredit the nature of racial microaggressions. Also described are the very real harms caused by racial microaggressions, with new frameworks for measurement and intervention. These articles reorient the field to this pertinent and pervasive problem and pave the way for action-based responses and interventions. The next step in the research must be to develop interventions to remedy the harms caused by microaggressions on victims. Further, psychology must make a fervent effort to root out racism that prevents scholarship on these topics from advancing.

The experiences of medical students, residents, fellows, and attendings in the emergency department: Implicit bias to microaggressions

OBJECTIVES

Microaggressions and implicit bias occur frequently in medicine. No previous study, however, has examined the implicit bias and microaggressions that emergency medicine (EM) providers experience. Our primary objective was to understand how often EM providers experience implicit bias and microaggressions. Our secondary objective was to evaluate the types of microaggressions they experience and whether their own identifying characteristics are risk factors.

METHODS

A questionnaire was administered to EM providers across the United States. Outcome measures of experiencing or witnessing a microaggression, overt discrimination, or implicit bias were described using frequencies, proportions, and logistic regressions. Where a univariate association between outcome measures and demographic characteristics was found, multivariate regression to estimate odds ratios (ORs) and 95% confidence intervals (95% CIs) was performed. Proportional odds logistic regression models were used to evaluate the specific type of microaggressions experienced and if there was an association with demographic variables.

RESULTS

A total of 277 medical providers (48% trainees-medical students, residents, and fellows-and 52% attending physicians) completed the survey. A total of 181 (65%) respondents reported experiencing a microaggression. Female (OR = 5.9 [95% CI = 3.1 to 11.2]) and non-White respondents (OR = 2.4 [95% CI = 1.2 to 4.5]) were more likely to report experiencing any microaggression. Misidentification, the most common form of microaggression, was more common with trainees compared to attending physicians (proportional OR [POR] = 2.6 [95% CI = 1.7 to 4.0]) and non-White, compared to White, respondents (POR = 2.2 [95% CI = 1.3 to 3.6]). Misidentification as nonclinician staff was associated with gender (POR = 53 [95% CI = 24 to 116]) and 52% of female respondents reported being mistaken for nonclinician staff almost daily. Seventy-six percent of respondents reported being called a vulgar term by a patient and 21% by a staff member.

CONCLUSIONS

EM providers, particularly women and non-Whites, who responded to our survey experienced and witnessed bias and microaggressions, most commonly misidentification, in the ED.

This is our lane: talking with patients about racism

Racism has significantly impacted communities of color for centuries. The year 2020 is a reminder that racism is an ongoing public health crisis. Healthcare institutions have an important role in dismantling racism because of their ability to implement innovative solutions that advance diversity, address social determinants of health, and promote health equity. Healthcare professionals have the unique opportunity to support patients by discussing patients' experiences of bias and racism. Asking about discrimination, however, can be difficult because of the sensitive nature of the topic and lack of appropriate education. This review highlights the importance of addressing patients' experiences of racism, utilizing the frameworks of trauma-informed care, structural competency, provider bias, and intersectionality. Furthermore, this review provides ways to engage in meaningful dialogue around discrimination and includes important patient-centric resources.

Guidance for Behavior Analysts in Addressing Racial Implicit Bias

In the practice of applied behavior analysis (ABA) treatment, implicit bias, which can be defined in behavioral terms, needs to be addressed because it may inadvertently lead to overt forms of discrimination on the basis of race. Although little research has been conducted within the field of ABA on racial implicit bias, information gathered from related fields can provide insight as to how behavior analysts can promote positive change in this area. Drawing from existing literature, recommendations are provided regarding assessment and administration of interventions to reduce racial implicit bias for clinicians. The purpose of this article is to provide strategies that behavior analysts can implement to assess and reduce behaviors related to implicit bias exhibited by practitioners, thereby reducing racial discrimination with clients and staff.

Racial Bias Among Emergency Providers: Strategies to Mitigate Its Adverse Effects

The Research to Practice column presents an analysis of current and controversial research findings with implications for practice change relevant to emergency care settings. This review critiques Johnson et al.'s (2016) investigation, titled "The Impact of Cognitive Stressors in the Emergency Department on Physician Implicit Racial Bias," that examined emergency department characteristics and stressors and their effects on physician racial bias and decision making. Their findings suggest that unconscious biases can affect clinical decisions when providers experience increased cognitive stress. The implications are significant for emergency providers as resources are especially strained during the COVID-19 pandemic and as the adverse effects of unconscious bias on health disparities and patient outcomes have become clearly apparent. Implicit bias training (IBT) is recommended for emergency providers and has significant implications for medical and nurse educators in executing and evaluating IBT outcomes.

Culture and psychedelic psychotherapy: Ethnic and racial themes from three Black women therapists

Psychedelic medicine is an emerging field of research and practice that examines the psychotherapeutic effects of substances classified as hallucinogens on the human mind, body, and spirit. Current research explores the safety and efficacy of these substances for mental health disorders including anxiety, depression, and posttraumatic stress disorder (PTSD). Although current studies explore psychotherapeutic effects from a biomedical perspective, gaps in awareness around cultural issues in the therapeutic process are prominent. African Americans have been absent from psychedelic research as both participants and researchers, and little attention has been paid to the potential of psychedelics to address traumas caused by racialization. This paper examines cultural themes and clinical applications from the one-time use of 3,4-methylenedioxymethamphetamine (MDMA) as part of an US Food and Drug Administration (FDA)-approved clinical trial and training exercise for three African American female therapists. The primary themes that emerged across the varied experiences centered on strength, safety, connection, and managing oppression/racialization. The participants' experiences were found to be personally meaningful and instructive for how Western models of psychedelic-assisted psychotherapy could be more effective and accessible to the Black community. Included is a discussion of the importance of facilitator training to make best use of emerging material when it includes cultural, racial, and spiritual themes. A lack of knowledge and epistemic humility can create barriers to treatment for underserved populations. Implications for future research and practice for marginalized cultural groups are also discussed, including consideration of Functional Analytic Psychotherapy (FAP) as an adjunct to the psychedelic-therapy approaches currently advanced. As women of color are among the most stigmatized groups of people, it is essential to incorporate their perspectives into the literature to expand conversations about health equity.