Reducing obesity prejudice in medical education

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.

Disorienting or Transforming? Using the Arts and Humanities to Foster Social Advocacy

Introduction

The arts and humanities (AH) have transformative potential in medical education. Research suggests that AH-based pedagogies may facilitate both personal and professional transformation in medical learners, which may then further enhance the teaching and learning of social advocacy skills. However, the potential for such curricula to advance social advocacy training remains under-explored. Therefore, we sought to identify how AH may facilitate transformative learning of social advocacy in medical education.

Methods

Building upon previous research, we conducted a critical narrative review seeking examples from the literature on how AH may promote transformative learning of social advocacy in North American medical education. Through a search of seven databases and MedEdPORTAL, we identified 11 articles and conducted both descriptive and interpretative analyses of their relation to key tenets of transformative learning, including: disorientation/dissonance, critical reflection, and discourse/dialogue.

Results

We found that AH are used in varied ways to foster transformative learning in social advocacy. However, most approaches emphasize their use to elicit disorientation and dissonance; there is less evidence in the literature regarding how they may be of potential utility when applied to disorienting dilemma, critical reflection, and discourse/dialogue.

Discussion

The tremendous potential of AH to foster transformative learning in social advocacy is constrained due to minimal attention to critical reflection and dialogue. Future research must consider how novel approaches that draw from AH may be used for more robust engagement with transformative learning tenets in medical education.

Medical students' perceived comfort and competence performing physical examinations on patients with obesity: A mixed-methods needs assessment

Physicians are unsatisfied with their training in the care of patients with obesity. Physical examination is a key component of care, and modifications to techniques are often necessary for patients with obesity. To determine learning needs, we examined medical students' perceived comfort and competency in conducting physical examinations on patients with obesity. This mixed-methods study of Canadian medical students used a questionnaire and semi-structured focus groups to assess medical students' perceived comfort and competence in examining patients with obesity. Participants included 175 Canadian medical students. A minority of medical students felt comfortable (42%) or competent (14%) examining patients with obesity. Physical exam challenges included modifying exam manoeuvres, interpreting findings and communicating sensitively around weight. Lack of early exposure to patients with obesity, minimal instruction by preceptors and a lack of curricular focus on obesity were felt to be barriers to improving these skills. Students perceived their lack of confidence as negatively impacting their ability to manage patients with obesity and more training in this area was desired to prevent disparities in care. Medical students feel that adequate training on how to perform an obesity-specific physical examination is lacking. Developing curricula and including formal teaching around these key competencies within medical education is essential.

Obesity bias awareness decreases nursing students' bias toward patients with obesity

PURPOSE

To determine if obesity bias scores among nursing students changed after education was delivered and to what degree body mass index (BMI) was associated with a personal experience of bias during a student's healthcare history.

METHODS

A quantitative, quasi-experimental design was used to analyze sociodemographic information and Implicit Association Test scores of junior, senior, and full-time accelerated coursework track nursing students.

RESULTS

Generally, obesity bias declined among the group. However, bias increased regarding increasing BMI.

CONCLUSION

Obesity bias awareness and obesity education can decrease obesity bias among nursing students.

A Multi-Modality Intervention Improves Obesity Bias among Medical Students

Background: Obesity is linked to chronic diseases in adults and children. Its prevalence continues to grow in the United States, necessitating the need for healthcare provider training and presenting an opportunity for the education of future medical providers. Despite this need, effectively implementing obesity education into medical school curricula has been challenging. Anti-obesity bias amongst healthcare providers and trainees represents a significant obstacle to the care of patients with obesity. Obesity bias may affect up to 1/3 of medical students. Methods: This study describes the development and preliminary testing of a brief, 2.5 h multi-modality teaching intervention consisting of online, interactive, and independent learning modules for first-year medical students and a patient panel focused on obesity, obesity bias, and motivational interviewing. The participants took Crandall's anti-fat attitude (AFA) questionnaire before and after an online independent learning module on motivational interviewing and obesity bias. The AFA consists of three subscales ("dislike", "fear of fat", and "willpower"). Individual responses were measured using a nine-point Likert-type response format (0 = very strongly disagree; 9 = very strongly agree). An average composite score was calculated for each subscale. Results: Data were analyzed from 103 first-year medical students enrolled at a college of medicine in the southwestern United States in 2022. The AFA mean composite scores decreased significantly, indicating a decrease in explicit anti-obesity attitude bias after completing the online module. This decrease was present in all three domains of fear (4.63 vs. 3.72, p < 0.001), dislike (1.25 vs. 0.88, p < 0.001) and willpower (3.23 vs. 2.31, p < 0.001). Conclusions: Relatively brief educational interventions can positively impact students' anti-obesity attitudes.

A scoping review to identify and organize literature trends of bias research within medical student and resident education

BACKGROUND

Physician bias refers to the unconscious negative perceptions that physicians have of patients or their conditions. Medical schools and residency programs often incorporate training to reduce biases among their trainees. In order to assess trends and organize available literature, we conducted a scoping review with a goal to categorize different biases that are studied within medical student (MS), resident (Res) and mixed populations (MS and Res). We also characterized these studies based on their research goal as either documenting evidence of bias (EOB), bias intervention (BI) or both. These findings will provide data which can be used to identify gaps and inform future work across these criteria.

METHODS

Online databases (PubMed, PsycINFO, WebofScience) were searched for articles published between 1980 and 2021. All references were imported into Covidence for independent screening against inclusion criteria. Conflicts were resolved by deliberation. Studies were sorted by goal: 'evidence of bias' and/or 'bias intervention', and by population (MS or Res or mixed) andinto descriptive categories of bias.

RESULTS

Of the initial 806 unique papers identified, a total of 139 articles fit the inclusion criteria for data extraction. The included studies were sorted into 11 categories of bias and showed that bias against race/ethnicity, specific diseases/conditions, and weight were the most researched topics. Of the studies included, there was a higher ratio of EOB:BI studies at the MS level. While at the Res level, a lower ratio of EOB:BI was found.

CONCLUSIONS

This study will be of interest to institutions, program directors and medical educators who wish to specifically address a category of bias and identify where there is a dearth of research. This study also underscores the need to introduce bias interventions at the MS level.

The impact of theatre on social competencies: a meta-analytic evaluation

BACKGROUND

There has been agrowing interest in using artistic interventions as a method of developing interpersonal competence. This paper presents a meta-analysis evaluating the impact of theatre interventions on social competencies.

METHODS

Twenty-one primary studies totaling 4064 participants were included, presenting evidence available since 1983. Included studies were assessed in terms of quality, heterogeneity, and publication bias.

RESULTS

Our findings indicated that active theatre participation significantly improved participants' empathic abilities, social communication, tolerance, and social interactions, with the largest pooled effect size for social communication (0.698) and the smallest for tolerance (0.156). Our findings did not corroborate the impact of theatre on self-concept.

CONCLUSIONS

This paper shows that theatre interventions have a positive impact on social competencies. The paper makes a methodological contribution by showing that randomized and non-randomized studies yielded comparably valid results.

An Educational Session for Medical Students Exploring Weight Bias in Clinical Care Through the Lens of Body Diversity

Introduction

Weight bias is pervasive in health care and can lead to inadequate care for people with higher weight. However, few medical schools offer training on mitigating weight bias and incorporating body diversity into clinical care.

Methods

As part of a course for second-year medical students, we developed and implemented a 3-hour multimodal educational session on mitigating weight bias. Didactics included content on body diversity and addressing weight bias, followed by a facilitated case discussion in small groups focused on debunking common myths related to weight. Assessment consisted of an open-content quiz and evaluation of a postsession survey. We performed a thematic analysis of the essay quiz responses and evaluation survey results.

Results

Three hundred fifty-three students participated in academic years 2020-2021 and 2021-2022. In the postsession quiz, students described several learning points, including understanding environmental influences on body size, improving communication by reducing weight bias, and strengthening the patient-provider relationship. In the postsession evaluation, students reported that their knowledge and skills had improved with respect to the learning objectives, with means of 4.0-4.1 on a 5-point Likert scale. Areas for suggested improvement included more time for discussion and more guidance on weight-inclusive care.

Discussion

This multimodal educational session on weight bias was successful in meeting the stated learning objectives. Future work will consist of building on this content and extending future iterations to residents and attendings, with the goal of disrupting harmful assumptions and improving access to holistic, evidence-based care for all people, regardless of size.

Educational strategies in the health professions to mitigate cognitive and implicit bias impact on decision making: a scoping review

BACKGROUND

Cognitive and implicit biases negatively impact clinicians' decision-making capacity and can have devastating consequences for safe, effective, and equitable healthcare provision. Internationally, health care clinicians play a critical role in identifying and overcoming these biases. To be workforce ready, it is important that educators proactively prepare all pre-registration healthcare students for real world practice. However, it is unknown how and to what extent health professional educators incorporate bias training into curricula. To address this gap, this scoping review aims to explore what approaches to teaching cognitive and implicit bias, for entry to practice students, have been studied, and what are the evidence gaps that remain.

METHODS

This scoping review was guided by the Joanna Briggs Institute (JBI) methodology. Databases were searched in May 2022 and included CINAHL, Cochrane, JBI, Medline, ERIC, Embase, and PsycINFO. The Population, Concept and Context framework was used to guide keyword and index terms used for search criteria and data extraction by two independent reviewers. Quantitative and qualitative studies published in English exploring pedagogical approaches and/or educational techniques, strategies, teaching tools to reduce the influence of bias in health clinicians' decision making were sought to be included in this review. Results are presented numerically and thematically in a table accompanied by a narrative summary.

RESULTS

Of the 732 articles identified, 13 met the aim of this study. Most publications originated from the United States (n=9). Educational practice in medicine accounted for most studies (n=8), followed by nursing and midwifery (n=2). A guiding philosophy or conceptual framework for content development was not indicated in most papers. Educational content was mainly provided via face-to-face (lecture/tutorial) delivery (n=10). Reflection was the most common strategy used for assessment of learning (n=6). Cognitive biases were mainly taught in a single session (n=5); implicit biases were taught via a mix of single (n=4) and multiple sessions (n=4).

CONCLUSIONS

A range of pedagogical strategies were employed; most commonly, these were face-to-face, class-based activities such as lectures and tutorials. Assessments of student learning were primarily based on tests and personal reflection. There was limited use of real-world settings to educate students about or build skills in biases and their mitigation. There may be a valuable opportunity in exploring approaches to building these skills in the real-world settings that will be the workplaces of our future healthcare workers.

Teaching module for obesity bias education: incorporating comprehensive competencies and innovative techniques

BACKGROUND

The majority of the United States population is overweight or obese, and obesity bias is frequently reported by patients. Obesity bias is associated with adverse health outcomes, even independent of body weight. Primary care residents are often sources of obesity bias towards patients with weight, yet education regarding obesity bias is significantly lacking in most family medicine residency teaching curricula. The aim of this study is to describe an innovative web-based module on obesity bias and discuss its impact in family medicine residents.

METHODS

The e-module was developed by an interprofessional team of health care students and faculty. It consisted of a 15-minute video containing five clinical vignettes that depicted instances of explicit and implicit obesity bias in a patient-centered medical home (PCMH) model. Family medicine residents viewed the e-module as part of a dedicated one-hour didactic on obesity bias. Surveys were administered prior to and following the viewing of the e-module. They assessed previous education on obesity care, comfort in working with patients with obesity, residents' understanding of their own biases in working with this population, and the anticipated impact of the module on future patient care.

RESULTS

A total of 83 residents from three family medicine residency programs viewed the e-module and 56 completed both the pre and post survey. There was a significant improvement in residents' comfort in working with patients with obesity as well as their understanding of their own biases.

CONCLUSION

This teaching e-module is a short, interactive, web-based educational intervention that is free and open-sourced. The first-person patient perspective allows learners to better understand the patient's point of view and its PCMH setting illustrates interactions with a variety of healthcare professionals. It was engaging and well received by family medicine residents. This module can begin the conversation around obesity bias, leading to improved patient care.

We Must Address the Antiobesity Biases We Espouse in Our Operating Rooms

OBJECTIVE

To describe anti-obesity bias in medical education including impact on patients, growth of biases over time, and education-based initiatives aimed at reducing bias.

DESIGN

We reviewed available literature on anti-obesity bias in medical education and initiatives to address this bias.

SETTING

Information from a wide variety of medical educational settings was included.

PARTICIPANTS

N/A RESULTS: Anti-obesity bias in healthcare is an independent risk factor for poor health outcomes and is pervasive throughout the culture of medicine. Medical students identify operating rooms as the number one location for anti-obesity comments, and students' biases increase throughout medical school. We propose several interventions (the 6 I's) as the next step in addressing this bias.

Creating an inclusive climate within pharmacy practice

OBJECTIVE

Identify the impact of a brief, educational intervention on student pharmacist understanding of unconscious bias and its systemic effects; cultural humility; and commitment to change.

METHODS

A pre-intervention survey, with questions utilizing a five-point Likert scale was embedded into the beginning of a series of online, interactive, educational modules addressing cultural humility, unconscious bias, and inclusive pharmacy practices. Third-year professional pharmacy students completed the course as part of their curriculum. At the conclusion of the modules, participants completed the post-intervention survey with the same set of questions, which was linked to the pre-intervention survey by a participant-generated code. Changes in means for the pre- and post-intervention cohorts were calculated and analyzed utilizing a Wilcoxon signed-rank test. Responses were also grouped dichotomously and evaluated using the McNemar test.

RESULTS

Sixty-nine students completed both the pre- and post-intervention surveys. The greatest change on Likert scale questions was noted in understanding of cultural humility (+1.4). Much or complete confidence in being able to describe unconscious bias and cultural competence improved from 58% to 88% and 14% to 71%, respectively (P < .05). Although a trend toward positive change was noted, a significant impact was not observed for questions assessing understanding of their systemic effects and commitment to change.

CONCLUSION

Interactive educational modules positively impact student understanding of unconscious bias and cultural humility. Further investigation is necessary to determine if continuous exposure to this and similar topics deepens student understanding of systemic impact and commitment to change.

Exploring the Effect of Adding an Interactive Lecture to a Standardized Patient Curriculum on the Attitudes of Third-Year Medical Students About Patients With Obesity: A Quasi-Experimental Study

OBJECTIVES

Anti-obesity bias is pervasive among medical professionals, students, and trainees. Stigmatization of patients leads to suboptimal care and clinical outcomes. Educational strategies in medical training are needed to reverse these attitudes. The aim of this study was to evaluate the effect of an innovative didactic intervention and a standardized patient (SP) exercise on attitudes towards patients with obesity among medical students.

METHODS

In 2016, a quasi-experimental study design was used at a US medical school. The class was divided into 2 groups according to a pre-determined protocol based on their clinical schedule, one assessed after exposure to a SP group and the other after exposure to the SP and an interactive lecture (IL + SP group) with real patients. The Attitudes about Treating Patients with Obesity and The Perceived Causes of Obesity questionnaires measured changes in several domains. A generalized estimating equations model was used to estimate the effect of the interventions both within and between groups.

RESULTS

Both groups showed improvements in negative and positive attitudes, although the reduction in scores for the negative attitude domain did not reach statistical significance in the IL + SP group (for the SP group, P = .01 and  < .001, respectively; for the IL + SP group, P = .15 and .01, respectively). For perceived causes of obesity, there were no statistically significant changes for pre-post survey measures within each group, except for the physiologic causes domain in the SP group (P = .03). The addition of an IL to a SP curriculum did not result in any changes for any domain in between-group analyses.

CONCLUSIONS

Although adding a novel intervention utilizing real patients to a SP curriculum failed to show an additional educational benefit, our study showed that it is possible to influence attitudes of medical students regarding patients with obesity.

Implicit Bias Training in Health Professions Education: A Scoping Review

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

Supplementary Information

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

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.

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

Health care providers hold negative explicit and implicit biases against marginalized groups of people such as racial and ethnic minoritized populations. These biases permeate the health care system and affect patients via patient–clinician communication, clinical decision making, and institutionalized practices. Addressing bias remains a fundamental professional responsibility of those accountable for the health and wellness of our populations. Current interventions include instruction on the existence and harmful role of bias in perpetuating health disparities, as well as skills training for the management of bias. These interventions can raise awareness of provider bias and engage health care providers in establishing egalitarian goals for care delivery, but these changes are not sustained, and the interventions have not demonstrated change in behavior in the clinical or learning environment. Unfortunately, the efficacy of these interventions may be hampered by health care providers’ work and learning environments, which are rife with discriminatory practices that sustain the very biases US health care professions are seeking to diminish. We offer a conceptual model demonstrating that provider-level implicit bias interventions should be accompanied by interventions that systemically change structures inside and outside the health care system if the country is to succeed in influencing biases and reducing health inequities.

Addressing Bias Toward Overweight Patients: a Training Program for First-Year Medical Students

BACKGROUND

Physicians may have biases toward overweight patients which likely influences clinical judgments and can lead to disparities in patient care. An increasing number of adults are considered overweight/obese, so it is important to address these biases in training future physicians.

METHODS

Forty-five first-year medical students participated in art museum programs and physician presentations, or were part of the control group. Four validated measures Beliefs About Obese Persons Scale, Attitudes Toward Obese Persons Scale, Fat Phobia Scale, and the Harvard Implicit Association Test (IAT) and researcher-generated questions, measured levels of bias before and after study activities.

RESULTS

All participants demonstrated decreased bias. ANCOVA analysis did not reveal significant differences between the experimental and control groups. However, prior to the study 75% of participants had "preference for thin individuals." Forty percent of those participating in study activities indicated a positive change by associating more positive traits with obese body shapes, compared to 29% of the control group. Study activities were rated positively.

DISCUSSION/CONCLUSION

The art museum was an engaging/relaxing place for reflection on body types and biases. Physicians provided important instruction for normalization/de-stigmatization of patient care. Although there were no significant findings, the study has raised questions for continuing this work. What are most effective ways/times to address weight bias within the medical school curriculum? Could this work extend to other marginalized patient groups? The diversity in art and humanities creates a rich resource for discussing viewpoints and experiences. The small number of participants and the timing/lack of focus in museum sessions are noted as limitations.

The "difficult" cadaver: weight bias in the gross anatomy lab

Background: The prevalence of overweight and obesity continues to rise and is associated with increased morbidity and mortality. Weight bias is common among physicians and medical students and limits the therapeutic alliance between providers and patients with overweight and obesity.Objective: The authors sought to explore the relationship between the gross anatomy course and medical student attitudes towards weight and obesity.Design: The authors employed a mixed-methods approach consisting of semi-structured interviews and anonymous web-based surveys of first-year medical students taking gross anatomy at one USA medical school. They analyzed transcripts of interviews and free-text survey responses using a grounded theory approach and performed tests of association to investigate the relationship between demographic information, responses to multiple-choice survey questions and weight bias.Results: A total of 319 (52%) first-year medical students (2015-2018) completed the survey and 33 participated in interviews. Of survey respondents, 71 (22%) responded that the course had changed how they felt about people with overweight/obesity. These respondents were also more likely to affirm that the course had affected their views toward their own bodies (p < 0.001). Qualitative data analysis identified three overarching themes within students' descriptions of the effects of the gross anatomy lab on attitudes toward bodies perceived to have excess weight: these bodies were described as 1) difficult, 2) unhealthy, and 3) evoking disgust. Students extrapolated from their experiences with cadavers to imagined interactions with future patients, relying heavily on the narrative of the difficult patient.Conclusions: At one USA medical school, students perceived their experiences in gross anatomy as shaping their attitudes toward individuals with overweight or obesity. Efforts to reduce medical student weight bias ought to target this previously unexplored potential site of weight bias.

A Systematic Review Of Implicit Attitudes And Their Neural Correlates In Eating Behaviour

An increasing number of studies suggests that implicit attitudes toward food and body shape predict eating behaviour and characterize patients with eating disorders (EDs). However, literature has not been previously analysed, thus differences between patients with EDs and healthy controls and the level of automaticity of the processes involved in implicit attitudes are still matters of debate. The present systematic review aimed to synthetize current evidence from papers investigating implicit attitudes towards food and body in healthy and EDs populations. PubMed, EMBASE (Ovid), PsycINFO, Web of Science and Scopus were systematically screened and 183 studies using different indirect paradigms were included in the qualitative analysis. The majority of studies reported negative attitudes towards overweight/obese body images in healthy and EDs samples and weight bias as a diffuse stereotypical evaluation. Implicit food attitudes are consistently reported as valid predictors of eating behaviour. Few studies on the neurobiological correlates showed neurostimulation effects on implicit attitudes, but the automaticity at brain level of implicit evaluations remains an open area of research. In conclusion, implicit attitudes are relevant measures of eating behaviour in healthy and clinical settings, although evidence about their neural correlates is limited.

Relationship Between Health-Promoting Lifestyle and Body Mass Index in Male Nurses Based on Demographic Variables

Behaviors such as an appropriate diet, physical activities, health responsiveness such as attending diagnoses and treatment recommendations, preventing from known health risks such as smoking, allocating time to rest and peace and managing stress are related to health-promoting lifestyles (HPLs). The objective of the current study was to determine the relationship between HPL and body mass index (BMI) of male nurses based on demographic variables. A descriptive correlation survey was conducted among 108 male nurses using the nonprobability sampling technique. Data were gathered through a questionnaire consisting of two parts: demographic characteristics and Pender's health promotion questionnaire. Data were analyzed by presenting measures, mean, standard deviation, independent t-test, Pearson's coefficient correlation, and one-way analysis of variance (ANOVA), using SPSS version 22. The mean score for male nurses' HPL was good (3.13). The highest mean was from spiritual growth (3.48) and the lowest was from physical activity (2.69). Approximately 24.07% participants were overweight and obese. The mean of HPL in normal-weight people was better than that of obese ones. Participants did not pay much attention to their family's health-promoting behaviors. They also were exposed to occupational hazards, including psychological (47.2%), ergonomic (21.7%), physical (20.8%), and biological hazards (10.4%). There was no significant relationship between age (p = .14), educational level (p = .95), marital status (p = .32), job experiences (p = .17), and HPL variables. As health providers, nurses should both provoke patients to attain their health and to strive to maintain and sustain their own health, especially for obesity prevention. From society's perspective, a nurse is one who knows more and acts better; therefore, paying attention to nurses' HPL is a professional and social expectation.

The Effectiveness of Teaching Clinical Empathy to Medical Students: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

PURPOSE

Clinical empathy is a necessary trait to provide effective patient care, despite differences in how it is defined and constructed. The aim of this study was to examine whether empathy interventions in medical students are effective and how confounding factors potentially moderate this effect.

METHOD

The authors performed a systematic review and meta-analysis. They searched the literature published between 1948 and 2018 for randomized controlled trials that examined empathy interventions in medical students. The search (database searching, citation tracking, hand-searching relevant journals) yielded 380 studies, which they culled to 16 that met the inclusion criteria. For the meta-analysis, they used a random effects model to produce a pooled estimate of the standardized mean difference (SMD), then completed subgroup analyses.

RESULTS

The authors found evidence of the possibility of response and reporting bias. The pooled SMD was 0.68 (95% confidence interval 0.43, 0.93), indicating a moderately positive effect of students developing empathy after an intervention compared with those in the control groups. There was no evidence of publication bias, but heterogeneity was significantly high (I = 88.5%, P < .01). Subgroup analyses indicated that significant moderating factors for developing empathy were age, country, scope of empathy measurement, type of empathy intervention, and presence of rehearsal. Moderating factors with limited evidence were sex, study quality, journal impact factor, and intervention characteristics.

CONCLUSIONS

Despite heterogeneity and biases, empathy interventions in medical students are effective. These findings reinforce arguments in the literature and add considerable rigor from the meta-analysis. The authors propose a conceptual model for educators to follow when designing empathy interventions in medical students.

Concept of overweight bias among healthcare professionals: An evolutionary concept analysis

The aim of this concept analysis was to identify the attributes of overweight bias among healthcare providers (HCPs) and create a clear definition to guide the recognition of overweight bias among HCPs. Settings within the healthcare system are not exempt from bias and the stigmatization of persons with obesity. Overweight bias among HCPs may negatively impact health care and health outcomes. Rodger's evolutionary method was used to guide this concept analysis. The databases CINAHL Plus with Full Text, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, MEDLINE, and PsycINFO were searched. The analysis provided clarification of the concept to facilitate HCP self-awareness of overweight bias. A definition of the concept of overweight bias among HCPs is provided along with its attributes, antecedents, and consequences.

How can Artistic Paintings Broaden Medical Students' Understanding of the Radiology Profession?

RATIONALE AND OBJECTIVES

The purpose of this study is to explore how representational paintings of radiology encounters with patients may impact medical students' understanding and impression of both radiologists and the radiology profession.

METHODS

Participants included third year medical students at a single institution rotating through a one-week radiology elective. Three works of art were analyzed using the validated Visual Thinking Strategies technique. Data collected included a postsession questionnaire and transcriptions of audio-recorded sessions. Data analysis involved both qualitative and quantitative methodology.

RESULTS

Fifty students participated; all participants completed the postsession questionnaire and 10 participated in the audio recorded sessions. Total 82% found the experience "very enjoyable" and 86% agreed that the paintings positively affected their understanding of how radiologists provide care to patients; 96% would recommend this session to others. Exploring representational paintings of radiology encounters seemed to influence perception and understanding of radiology with students reporting "light bulb moments;" create a dissonance between the student experience and the experience depicted in the paintings; and address gaps in content specific knowledge.

CONCLUSION

The findings of this study suggest that analyzing paintings depicting radiology encounters with patients can challenge negative stereotypes that medical students have of the radiology profession and radiologists. This arts-based learning module employing a learning strategy such as Visual Thinking Strategies, should be considered by the radiology profession as a strategy to positively inform and educate trainees about the specialty.

Obesity education in medical schools, residencies, and fellowships throughout the world: a systematic review

Obesity is pandemic throughout the world, and there is concern that physicians are inadequately trained to treat their patients with obesity despite its prevalence. This review explores obesity education in medical students, resident, and fellow physicians throughout the world from 2005 to 2018. Previous reviews on obesity education were conducted before 2011, focused solely on medical students, and only explored obesity education in the United States. We systematically searched MEDLINE, EMBASE, PsycINFO, and ERIC databases for studies which included the search terms "obesity education" AND either "medical students", "residency", or "fellowship" that met PICOS (Population, Interventions, Comparators, Outcomes, Study Design) criteria for articles published in English for obesity education and evaluation of outcomes. Our initial search yielded 234 articles, and 27 studies met criteria for our review. We described and analyzed these studies for their study design and graded quality, quantity, and consistency for each measured outcome. We applied an evidence grading system that has been previously applied in the literature in which each outcome measure was graded on a scale from A to D. We evaluated obesity education programs for outcomes regarding implicit and explicit bias, changes in attitude towards obesity, weight change, obesity knowledge, counseling confidence, intent to counsel, and counseling quality. There was a significant degree of heterogeneity in the studies included. While obesity knowledge was most frequently studied, counseling confidence was the only outcome with an overall grade A. There is currently a paucity of obesity education programs for medical students, residents, and fellow physicians in training programs throughout the world despite high disease prevalence. However, these programs often improve outcomes when they are administered. Our review suggests that more obesity education should be administered in undergraduate and graduate medical education to ensure optimal treatment of patients with obesity.

Fundamentals for an Osteopathic Obesity Designed Study: The Effects of Education on Osteopathic Medical Students' Attitudes Regarding Obesity

Context

Obesity is a major health concern in the United States, and its prevalence continues to rise. Although it is a common health issue, many people, including health care professionals, are biased against people with obesity.

Objective

To determine whether a comprehensive obesity curriculum presented to students in medical school can positively influence their attitudes toward obesity.

Methods

The study was designed around a comprehensive educational obesity curriculum at Touro University College of Osteopathic Medicine-CA, involving the classes of 2013 through 2018. A survey to assess student attitudes toward obesity was distributed to first-year students before the curriculum, directly after completion, and each year after until graduation (graduating classes of 2015 through 2018). Second- and third-year medical students in 2011 (graduating classes of 2014 and 2013), who did not complete the curriculum, were given an examination to establish baseline values and served as the control group. The obesity curriculum consisted of lectures delivered during the first and second year of medical school and case study simulations during the third year. Knowledge gained from the curriculum was assessed with a multiple-choice examination, and bias was assessed using the Fat Phobia Scale.

Results

A total of 718 first- through fourth-year students were included. Students who completed the first year of the obesity curriculum (n=528) showed significantly greater medical knowledge regarding obesity-related epidemiology, pathogenesis, biochemistry, pathophysiology, and metabolic factors; nutrition, diet, physical activity, self-control, and behavior modification; pharmacologic and nonpharmacologic interventions; and associated chronic disorders, based on their multiple-choice examination scores compared with the control group. The examination scores indicated significant increases in medical knowledge compared with the precurriculum cohort after the curriculum (OMS I students: 130 [72.4%]; 133 [92.6%]; 133 [91.1%]; 132 [89.0%]; vs control: 105 [47.2%]; 134 [52.6%], respectively [P<.01]). In all 4 years observed, there was a significant reduction in bias among first-year medical students after obesity curriculum (before: 3.65, 3.76, 3.57, 3.61, and after: 3.47, 3.38, 3.34, 3.37, respectively) (P<.05). The reduction in bias was also significantly sustained throughout the fourth year.

Conclusion

A comprehensive obesity curriculum throughout medical school resulted in an improvement in students' attitudes toward and knowledge of obesity.

Obesity Education in Medical School Curricula in Korea

Obesity is one of the three most common diseases, affecting about one-third of adults. Obesity also increases vulnerability to metabolic disorders, psychological disorders, and various cancers and decreases quality of life. Therefore, obesity must be adequately addressed in medical school. Here, I will review how obesity education is implemented in medical school curricula in Korea. Many studies have shown that students who are well educated about obesity through various educational methods reduce their prejudice toward obese patients. The Korean Society for the Study of Obesity is an interdisciplinary academy, including experts from fields such as general research, clinical practice, nutrition, nursing, exercise, and rehabilitation. They aim to identify the core competencies of obesity education necessary for medical students, develop curricula of obesity education, and present examples of lectures and discussions. In the future, health professionals who receive such education will be able to take better care of obese patients without bias.

Stigma Experienced by Children and Adolescents With Obesity

The stigmatization of people with obesity is widespread and causes harm. Weight stigma is often propagated and tolerated in society because of beliefs that stigma and shame will motivate people to lose weight. However, rather than motivating positive change, this stigma contributes to behaviors such as binge eating, social isolation, avoidance of health care services, decreased physical activity, and increased weight gain, which worsen obesity and create additional barriers to healthy behavior change. Furthermore, experiences of weight stigma also dramatically impair quality of life, especially for youth. Health care professionals continue to seek effective strategies and resources to address the obesity epidemic; however, they also frequently exhibit weight bias and stigmatizing behaviors. This policy statement seeks to raise awareness regarding the prevalence and negative effects of weight stigma on pediatric patients and their families and provides 6 clinical practice and 4 advocacy recommendations regarding the role of pediatricians in addressing weight stigma. In summary, these recommendations include improving the clinical setting by modeling best practices for nonbiased behaviors and language; using empathetic and empowering counseling techniques, such as motivational interviewing, and addressing weight stigma and bullying in the clinic visit; advocating for inclusion of training and education about weight stigma in medical schools, residency programs, and continuing medical education programs; and empowering families to be advocates to address weight stigma in the home environment and school setting.

A scoping review of weight bias by community pharmacists towards people with obesity and mental illness

BACKGROUND

Community pharmacists are accessible health care professionals who are increasingly offering weight management programs. People living with serious mental illness have markedly higher rates of obesity and associated illness outcomes than the general population, providing pharmacists who are interested in offering weight management services with an identifiable patient subgroup with increased health needs. Issues with stigma within obesity and mental illness care are prevalent and can lead to inequities and reduced quality of care.

METHODS

We conducted a scoping review to map and characterize the available information from published and grey literature sources regarding community pharmacists and weight bias towards obese people with lived experience of mental illness. A staged approach to the scoping review was used.

RESULTS

Six articles and 6 websites were abstracted after we removed duplicates and applied our inclusion and exclusion criteria. The published studies that we found indicated that pharmacists and pharmacy students do demonstrate implicit and explicit weight bias.

CONCLUSIONS

Very limited research is available regarding weight bias in pharmacists and stigma towards people with obesity, and we found no information on these phenomena relating to people with lived experience of mental illness. Investigations are needed to characterize the extent and nature of anti-fat bias and attitudes by pharmacists and the consequences of these attitudes for patient care.