Research ObjectiveClinicians’ implicit bias can affect quality of healthcare delivery and contrib... more Research ObjectiveClinicians’ implicit bias can affect quality of healthcare delivery and contribute to healthcare disparities. How to design an educational intervention to equip clinicians with skills to mitigate implicit bias without inducing defensiveness is unclear. COmmuNity‐engaged SimULation Training for Blood Pressure Control (CONSULT‐BP) Trial is a 5‐year clinical trial educational intervention designed in collaboration with racial, ethnic, and socioeconomically diverse representatives of the local patient community. CONSULT evaluates clinician trainee awareness of and defensiveness about implicit bias pre‐ and postexposure to a face‐to‐face simulation training with standardized patients (SPs) from local racial and ethnic communities.Study DesignPre‐post analysis of trainee bias awareness and defensiveness in the context of a clinical trial that evaluates the impact of an educational intervention to improve clinicians’ interaction skills with diverse populations. Participants completed two, in‐person educational sessions, 5 weeks apart. Learning components included the following: online modules on health disparities, implicit bias, and patient‐centered care; and face‐to‐face simulation encounters with diverse SPs. Four Implicit Association Tests (IATs) were used to measure implicit and explicit bias, and to promote self‐reflection. We measured pre/post bias awareness using a 7‐item Bias Awareness Scale and defensiveness using a 3‐item pre/post measure of reaction to feedback on implicit bias scores. We also collected trainee feedback about the educational experience.Population StudiedGraduate medical and nurse practitioner trainees, including internal medicine, family medicine residents, and nurse practitioner students. We present preliminary findings from CONSULT year 1 cohort (N = 86).Principal FindingsBoth before and after, the intervention participants slightly agreed that they are objective that bias does not affect their decision‐making, disagreed that society treats all groups equally, and that all people have equal opportunity. After the intervention, participants were significantly more likely to disagree with the statement that bias is no longer a problem in patient care (P = .00). In response to feedback on their IAT scores, participants were more likely to agree that the IAT reflects “something about my thoughts or feelings, unconscious or otherwise” (48% pre, 54%, post). Preintervention, 76% agreed that “the IAT captures something important about me” but only 58% agreed postintervention. When asked if the IAT reflects something about their “automatic thoughts and feelings” concerning racial/ethnic bias, 75% agreed preintervention and 65% agreed postintervention. Qualitative feedback from trainees reported that the intervention was a burden on their, taking numerous IATs was redundant, and identified an unmet need to address patient bias toward medical providers.ConclusionsDefensiveness about implicit bias scores increased after exposure to our educational program to mitigate implicit bias. Trainees identified challenges with our educational approach and study design.Implications for Policy or PracticeWe learned of the need to include trainee participants during the design phase of this type of training experience and refined our educational intervention for subsequent cohorts. Without sacrificing essential elements of education, investigators amended the study for years 2‐5 to a single session, one IAT per participant, streamlined content in educational modules and included more in‐person education by an educator with the experience and skills needed to facilitate discussion on this highly charged and complicated topic.Primary Funding SourceNational Institutes of Health.
Objective Few investigations have comprehensively assessed the scope of impairment of injured ado... more Objective Few investigations have comprehensively assessed the scope of impairment of injured adolescents presenting to acute care inpatient settings. Methods Randomly sampled injured adolescent inpatients and their parents were screened for posttraumatic stress (PTS) and depressive symptoms, preinjury alcohol use, and preinjury trauma. Linear regression was used to assess which clinical, demographic, and injury characteristics were independently associated with increased levels of adolescent PTS and depressive symptoms. Results Seventy percent of adolescent-parent dyads endorsed high levels of PTS or depressive symptoms and/or high preinjury alcohol use. Adolescent female gender, greater levels of preinjury trauma, greater subjective distress at the time of the injury, and greater parental depressive symptoms were independently associated with increased levels of adolescent PTS and depressive symptoms. Conclusions The adoption of early screening and intervention procedures that broadly consider the scope of impairment of injured adolescents and their family members could enhance the quality of acute care mental health service delivery.
Journal of Health Care for the Poor and Underserved, 2009
Recent reports suggest that providers' implicit attitudes about race contribute to racial and eth... more Recent reports suggest that providers' implicit attitudes about race contribute to racial and ethnic health care disparities. However, little is known about physicians' implicit racial attitudes. This study measured implicit and explicit attitudes about race using the Race Attitude Implicit Association Test (IAT) for a large sample of test takers (N = 404,277), including a sub-sample of medical doctors (MDs) (n = 2,535). Medical doctors, like the entire sample, showed an implicit preference for White Americans relative to Black Americans. We examined these effects among White, African American, Hispanic, and Asian MDs and by physician gender. Strength of implicit bias exceeded self-report among all test takers except African American MDs. African American MDs, on average, did not show an implicit preference for either Blacks or Whites, and women showed less implicit bias than men. Future research should explore whether, and under what conditions, MDs' implicit attitudes about race affect the quality of medical care.
Objectives. We examined the association between pediatricians’ attitudes about race and treatment... more Objectives. We examined the association between pediatricians’ attitudes about race and treatment recommendations by patients’ race. Methods. We conducted an online survey of academic pediatricians (n = 86). We used 3 Implicit Association Tests to measure implicit attitudes and stereotypes about race. Dependent variables were recommendations for pain management, urinary tract infections, attention deficit hyperactivity disorder, and asthma, measured by case vignettes. We used correlational analysis to assess associations among measures and hierarchical multiple regression to measure the interactive effect of the attitude measures and patients’ race on treatment recommendations. Results. Pediatricians’ implicit (unconscious) attitudes and stereotypes were associated with treatment recommendations. The association between unconscious bias and patient’s race was statistically significant for prescribing a narcotic medication for pain following surgery. As pediatricians’ implicit proWhite bias increased, prescribing narcotic medication decreased for African American patients but not for the White patients. Self-reported attitudes about race were associated with some treatment recommendations. Conclusions. Pediatricians’ implicit attitudes about race affect pain management. There is a need to better understand the influence of physicians’ unconscious beliefs about race on pain and other areas of care. (Am J Public Health. 2012;102:988–995. doi:10.2105/AJPH.2011.300621)
This study examines lifetime prevalence estimates of mental disorders among Asian Americans with ... more This study examines lifetime prevalence estimates of mental disorders among Asian Americans with a focus on differences by nativity, gender, and other relevant sociodemographic correlates. We analyze cross-sectional data from the National Latino and Asian American Study (NLAAS), the first national epidemiological survey of Asian Americans which used a probability sample of household resident adults in the United States (N=2,095). US-born Asian Americans are more likely to experience lifetime mood disorders, substance use disorders, and any mental disorders compared to immigrants. Lifetime substance use disorders are more likely to occur among men rather than women. Nativity and gender show joint associations with different mental disorders: US-born women are at the greatest risk for any mood disorders; US-born men are at the greatest risk for any substance use disorders; and immigrant women are at the lowest risk for substance use disorders compared to all other groups. Analysis of the sociodemographic correlates reveals that the youngest immigrant women showed significantly higher rates of any mood disorder compared to other immigrant women. Additionally, among immigrant men, those with low household income are at a higher risk for mood disorders, and those who report fair/poor English proficiency have a higher prevalence of anxiety and mood disorders. This study provides documentation of prevalence differences in detailed mental health categories along salient axes of stratification among Asian Americans and provides a foundation for future research aimed at understanding the causes and correlates of mental health disparities.
njury represents the leading cause of death and disabil-I ity for US children and adolescents.' A... more njury represents the leading cause of death and disabil-I ity for US children and adolescents.' Almost 16 million children are evaluated for injury each year in the United States.* Although childhood injury rates are decreasing, 70% of all deaths among children and adolescents aged 5 to 19 years are injury related. Nonfatal injury is the leading cause of both temporary and permanent disability for children 19 years and younger.' One quarter of children receive medical treatment in a hospital emergency room or are treated in private physicians' offices for injury a n n~a l l y .~ Of those hospitalized for trauma, more than one half experience some form of disability from their injury. Head injury has been the subject of most research on child injury disability, but trauma without head injury also has the potential to produce both short-and long-term di~ability.~ This paper highlights the need for increased awareness in schools regarding the vulnerability of injured children and adolescents and the role school health professionals can play as important resources for injured students and their families. FACTORS IN CHILDHOOD INJURY Mechanisms of injury to school-aged children and adolescents include unintentional and intentional injury. Unintentional injury includes injuries from motor vehicle crashes, pedestrian and cycling collisions, falls, drowning, and burns, while intentional injury encompasses injury from violence directed at others and self-inflicted injury. In a national study of nonfatal injuries resulting in hospitalization, motor vehicle crashes accounted for 20% of injuries to children aged 13 to 15 years and 46% of injuries to older adolescents.' Gunshot wounds and stabbing made up 20% of injuries to children in both the 13-to 15-year age group and the 16-to 18-year-olds.' Each year, 30,000 children in the United States acquire a permanent disability due to injury. For children, pedestrian injuries, falls, and motor vehicle and bicycle injuries are most likely to
Background: Recent reports speculate that provider implicit attitudes about race may contribute t... more Background: Recent reports speculate that provider implicit attitudes about race may contribute to racial/ethnic health care disparities. Objectives: We hypothesized that implicit racial bias exists among pediatricians, implicit and explicit measures would differ and implicit measures may be related to quality of care. Research Design: A single-session, Web survey of academic pediatricians in an urban university measured implicit racial attitudes and stereotypes using a measure of implicit social cognition, the Implicit Association Test (IAT). Explicit (overt) attitudes were measured by self-report. Case vignettes were used to assess quality of care. Results: We found an implicit preference for European Americans relative to African Americans, which was weaker than implicit measures for others in society (mean IAT score ϭ 0.18; P ϭ 0.01; Cohen's d ϭ 0.41). Physicians held an implicit association between European Americans relative to African Americans and the concept of "compliant patient" (mean IAT score ϭ 0.25; P ϭ 0.001; Cohen's d ϭ 0.60) and for African Americans relative to European Americans and the concept of "preferred medical care" (mean IAT score ϭ Ϫ0.21; P ϭ 0.001; Cohen's d ϭ 0.64). Medical care differed by patient race in 1 of 4 case vignettes. No significant relationship was found between implicit and explicit measures, or implicit measures and treatment recommendations. Conclusions: Pediatricians held less implicit race bias compared with other MDs and others in society. Among pediatricians we found evidence of a moderate implicit "perceived patient compliance and race" stereotype. Further research is needed to explore whether physician implicit attitudes and stereotypes about race predict quality of care.
Purpose: Breast surgery comprises a significant portion of plastic surgery. Given the high volume... more Purpose: Breast surgery comprises a significant portion of plastic surgery. Given the high volume of breast surgery procedures, it is a significant area of investigation in plastic surgery literature. The aim of this study was to use established photogrammetric analysis techniques to evaluate the visual representation of racial diversity in the published breast surgery literature and to understand how it compares to the general and plastic surgery patient population.
Journal of Medical Education and Curricular Development
Objectives To describe the development and refinement of an implicit bias recognition and managem... more Objectives To describe the development and refinement of an implicit bias recognition and management training program for clinical trainees. Methods In the context of an NIH-funded clinical trial to address healthcare disparities in hypertension management, research and education faculty at an academic medical center used a participatory action research approach to engage local community members to develop and refine a “knowledge, awareness, and skill-building” bias recognition and mitigation program. The program targeted medical residents and Doctor of Nursing Practice students. The content of the two-session training included: didactics about healthcare disparities, racism and implicit bias; implicit association test (IAT) administration to raise awareness of personal implicit bias; skill building for bias-mitigating communication; and case scenarios for skill practice in simulation-based encounters with standardized patients (SPs) from the local community. Results The initial tri...
European Archives of Psychiatry and Clinical Neuroscience, 1999
Background: This paper focuses on the lifetime prevalence of mental disorders in individuals with... more Background: This paper focuses on the lifetime prevalence of mental disorders in individuals with Turkish migration backgrounds in Germany, as there is a lack of reliable epidemiological data on this subject. Methods: In total, 662 adults with Turkish migration backgrounds were interviewed in Hamburg and Berlin by trained, bilingual interviewers using the computerized Composite International Diagnostic Interview (CIDI DIA-X Version 2.8) to assess diagnoses according to the DSM-IVTR. Results: The analyses showed a weighted lifetime prevalence of 78.8% for any mental disorder, 21.6% for more than one and 7.3% for five or more disorders. Any mood disorder (41.9%), any anxiety disorder (35.7%) and any somatoform disorder/syndrome (33.7%) had the highest prevalences. Despite the sociodemographic differences between the first and second generations, there were no significant differences in the lifetime prevalence between generations, with the exception of any bipolar disorder. Female gender, older age and no current partnership were significantly associated with the occurrence of any mood disorder. Conclusions: Overall, the results indicate a high lifetime prevalence in individuals with Turkish migration backgrounds in Germany. These initial data are highly relevant to the German clinical and psychosocial healthcare system; however, the methodological limitations and potential biases should be considered when interpreting the results.
IntroductionFewer than half of internal medicine program directors report any health disparities ... more IntroductionFewer than half of internal medicine program directors report any health disparities curriculum. We piloted a web-based healthcare disparities module among internal medicine (IM) residents to test effectiveness and feasibility, compared to a convenient sample of graduate students enrolled in a public health equity course.MethodsIM residents participated in an in-person session (module 1: introduction to racial and ethnic health disparities), but first, they completed a pre-module knowledge quiz. Two weeks later, they completed module 2: “unconscious associations” and a post-module knowledge quiz. For the control arm Yale School of Public Health (YSPH) students enrolled in a course on health disparities completed the pre-module knowledge quiz, module 1, and 2 as required by their course instructor.ResultsForty-nine IM residents and 22 YSPH students completed the pre-module quiz and Module 1. The mean (SD) score out of 25 possible points for the IM residents on the pre-mod...
Bias toward historically marginalized patients affects patient-provider interactions and can lead... more Bias toward historically marginalized patients affects patient-provider interactions and can lead to lower quality of care and poor health outcomes for patients who are Black, Indigenous, People of Color (BIPOC) and Lesbian, Gay, Bisexual, Transgender and Gender Diverse (LGBTQ+). We gathered experiences with biased healthcare interactions and suggested solutions from 25 BIPOC and LGBTQ+ people. Through qualitative thematic analysis of interviews, we identified ten themes. Eight themes reflect the experience of bias: Transactional Care, Power Inequity, Communication Casualties, Bias-Embedded Medicine, System-level problems, Bigotry in Disguise, Fight or Flight, and The Aftermath. The remaining two themes reflect strategies for improving those experiences: Solutions and Good Experiences. Characterizing these themes and their interconnections is crucial to design effective informatics solutions that can address biases operating in clinical interactions with BIPOC and LGBTQ+ patients, improve the quality of patient-provider interactions, and ultimately promote health equity.
Journal of the American Medical Informatics Association
Objective People who experience marginalization, including Black, Indigenous, People of Color (BI... more Objective People who experience marginalization, including Black, Indigenous, People of Color (BIPOC) and Lesbian, Gay, Bisexual, Transgender, Queer, Plus (ie, all other marginalized genders and sexual orientations) people (LGBTQ+) experience discrimination during healthcare interactions, which negatively impacts patient–provider communication and care. Yet, scarce research examines the lived experience of unfair treatment among patients from marginalized groups to guide patient-centered tools that improve healthcare equity. Materials and Methods We interviewed 25 BIPOC and/or LGBTQ+ people about their experiences of unfair treatment and discrimination when visiting healthcare providers. Through thematic analysis, we describe participants’ immediate reactions and longer-term consequences of those experiences. Results We identified 4 ways that participants reacted to discrimination in the moment: Fighting, Fleeing, Excusing, and Working Around Bias. Long-term consequences reflect 6 w...
CHI Conference on Human Factors in Computing Systems Extended Abstracts
Although clinical training in implicit bias is essential for healthcare equity, major gaps remain... more Although clinical training in implicit bias is essential for healthcare equity, major gaps remain both for effective educational strategies and for tools to help identify implicit bias. To understand the perspectives of clinicians on the design of these needed strategies and tools, we conducted 21 semi-structured interviews with primary care clinicians about their perspectives and design recommendations for tools to improve patient-centered communication and to help mitigate implicit bias. Participants generated three types of solutions to improve communication and raise awareness of implicit bias: digital nudges, guided reflection, and data-driven feedback. Given the nuance of implicit bias communication feedback, these findings illustrate innovative design directions for communication training strategies that clinicians may find acceptable. Improving communication skills through individual feedback designed by clinicians for clinicians has the potential to improve healthcare equity.
Research ObjectiveClinicians’ implicit bias can affect quality of healthcare delivery and contrib... more Research ObjectiveClinicians’ implicit bias can affect quality of healthcare delivery and contribute to healthcare disparities. How to design an educational intervention to equip clinicians with skills to mitigate implicit bias without inducing defensiveness is unclear. COmmuNity‐engaged SimULation Training for Blood Pressure Control (CONSULT‐BP) Trial is a 5‐year clinical trial educational intervention designed in collaboration with racial, ethnic, and socioeconomically diverse representatives of the local patient community. CONSULT evaluates clinician trainee awareness of and defensiveness about implicit bias pre‐ and postexposure to a face‐to‐face simulation training with standardized patients (SPs) from local racial and ethnic communities.Study DesignPre‐post analysis of trainee bias awareness and defensiveness in the context of a clinical trial that evaluates the impact of an educational intervention to improve clinicians’ interaction skills with diverse populations. Participants completed two, in‐person educational sessions, 5 weeks apart. Learning components included the following: online modules on health disparities, implicit bias, and patient‐centered care; and face‐to‐face simulation encounters with diverse SPs. Four Implicit Association Tests (IATs) were used to measure implicit and explicit bias, and to promote self‐reflection. We measured pre/post bias awareness using a 7‐item Bias Awareness Scale and defensiveness using a 3‐item pre/post measure of reaction to feedback on implicit bias scores. We also collected trainee feedback about the educational experience.Population StudiedGraduate medical and nurse practitioner trainees, including internal medicine, family medicine residents, and nurse practitioner students. We present preliminary findings from CONSULT year 1 cohort (N = 86).Principal FindingsBoth before and after, the intervention participants slightly agreed that they are objective that bias does not affect their decision‐making, disagreed that society treats all groups equally, and that all people have equal opportunity. After the intervention, participants were significantly more likely to disagree with the statement that bias is no longer a problem in patient care (P = .00). In response to feedback on their IAT scores, participants were more likely to agree that the IAT reflects “something about my thoughts or feelings, unconscious or otherwise” (48% pre, 54%, post). Preintervention, 76% agreed that “the IAT captures something important about me” but only 58% agreed postintervention. When asked if the IAT reflects something about their “automatic thoughts and feelings” concerning racial/ethnic bias, 75% agreed preintervention and 65% agreed postintervention. Qualitative feedback from trainees reported that the intervention was a burden on their, taking numerous IATs was redundant, and identified an unmet need to address patient bias toward medical providers.ConclusionsDefensiveness about implicit bias scores increased after exposure to our educational program to mitigate implicit bias. Trainees identified challenges with our educational approach and study design.Implications for Policy or PracticeWe learned of the need to include trainee participants during the design phase of this type of training experience and refined our educational intervention for subsequent cohorts. Without sacrificing essential elements of education, investigators amended the study for years 2‐5 to a single session, one IAT per participant, streamlined content in educational modules and included more in‐person education by an educator with the experience and skills needed to facilitate discussion on this highly charged and complicated topic.Primary Funding SourceNational Institutes of Health.
Objective Few investigations have comprehensively assessed the scope of impairment of injured ado... more Objective Few investigations have comprehensively assessed the scope of impairment of injured adolescents presenting to acute care inpatient settings. Methods Randomly sampled injured adolescent inpatients and their parents were screened for posttraumatic stress (PTS) and depressive symptoms, preinjury alcohol use, and preinjury trauma. Linear regression was used to assess which clinical, demographic, and injury characteristics were independently associated with increased levels of adolescent PTS and depressive symptoms. Results Seventy percent of adolescent-parent dyads endorsed high levels of PTS or depressive symptoms and/or high preinjury alcohol use. Adolescent female gender, greater levels of preinjury trauma, greater subjective distress at the time of the injury, and greater parental depressive symptoms were independently associated with increased levels of adolescent PTS and depressive symptoms. Conclusions The adoption of early screening and intervention procedures that broadly consider the scope of impairment of injured adolescents and their family members could enhance the quality of acute care mental health service delivery.
Journal of Health Care for the Poor and Underserved, 2009
Recent reports suggest that providers' implicit attitudes about race contribute to racial and eth... more Recent reports suggest that providers' implicit attitudes about race contribute to racial and ethnic health care disparities. However, little is known about physicians' implicit racial attitudes. This study measured implicit and explicit attitudes about race using the Race Attitude Implicit Association Test (IAT) for a large sample of test takers (N = 404,277), including a sub-sample of medical doctors (MDs) (n = 2,535). Medical doctors, like the entire sample, showed an implicit preference for White Americans relative to Black Americans. We examined these effects among White, African American, Hispanic, and Asian MDs and by physician gender. Strength of implicit bias exceeded self-report among all test takers except African American MDs. African American MDs, on average, did not show an implicit preference for either Blacks or Whites, and women showed less implicit bias than men. Future research should explore whether, and under what conditions, MDs' implicit attitudes about race affect the quality of medical care.
Objectives. We examined the association between pediatricians’ attitudes about race and treatment... more Objectives. We examined the association between pediatricians’ attitudes about race and treatment recommendations by patients’ race. Methods. We conducted an online survey of academic pediatricians (n = 86). We used 3 Implicit Association Tests to measure implicit attitudes and stereotypes about race. Dependent variables were recommendations for pain management, urinary tract infections, attention deficit hyperactivity disorder, and asthma, measured by case vignettes. We used correlational analysis to assess associations among measures and hierarchical multiple regression to measure the interactive effect of the attitude measures and patients’ race on treatment recommendations. Results. Pediatricians’ implicit (unconscious) attitudes and stereotypes were associated with treatment recommendations. The association between unconscious bias and patient’s race was statistically significant for prescribing a narcotic medication for pain following surgery. As pediatricians’ implicit proWhite bias increased, prescribing narcotic medication decreased for African American patients but not for the White patients. Self-reported attitudes about race were associated with some treatment recommendations. Conclusions. Pediatricians’ implicit attitudes about race affect pain management. There is a need to better understand the influence of physicians’ unconscious beliefs about race on pain and other areas of care. (Am J Public Health. 2012;102:988–995. doi:10.2105/AJPH.2011.300621)
This study examines lifetime prevalence estimates of mental disorders among Asian Americans with ... more This study examines lifetime prevalence estimates of mental disorders among Asian Americans with a focus on differences by nativity, gender, and other relevant sociodemographic correlates. We analyze cross-sectional data from the National Latino and Asian American Study (NLAAS), the first national epidemiological survey of Asian Americans which used a probability sample of household resident adults in the United States (N=2,095). US-born Asian Americans are more likely to experience lifetime mood disorders, substance use disorders, and any mental disorders compared to immigrants. Lifetime substance use disorders are more likely to occur among men rather than women. Nativity and gender show joint associations with different mental disorders: US-born women are at the greatest risk for any mood disorders; US-born men are at the greatest risk for any substance use disorders; and immigrant women are at the lowest risk for substance use disorders compared to all other groups. Analysis of the sociodemographic correlates reveals that the youngest immigrant women showed significantly higher rates of any mood disorder compared to other immigrant women. Additionally, among immigrant men, those with low household income are at a higher risk for mood disorders, and those who report fair/poor English proficiency have a higher prevalence of anxiety and mood disorders. This study provides documentation of prevalence differences in detailed mental health categories along salient axes of stratification among Asian Americans and provides a foundation for future research aimed at understanding the causes and correlates of mental health disparities.
njury represents the leading cause of death and disabil-I ity for US children and adolescents.' A... more njury represents the leading cause of death and disabil-I ity for US children and adolescents.' Almost 16 million children are evaluated for injury each year in the United States.* Although childhood injury rates are decreasing, 70% of all deaths among children and adolescents aged 5 to 19 years are injury related. Nonfatal injury is the leading cause of both temporary and permanent disability for children 19 years and younger.' One quarter of children receive medical treatment in a hospital emergency room or are treated in private physicians' offices for injury a n n~a l l y .~ Of those hospitalized for trauma, more than one half experience some form of disability from their injury. Head injury has been the subject of most research on child injury disability, but trauma without head injury also has the potential to produce both short-and long-term di~ability.~ This paper highlights the need for increased awareness in schools regarding the vulnerability of injured children and adolescents and the role school health professionals can play as important resources for injured students and their families. FACTORS IN CHILDHOOD INJURY Mechanisms of injury to school-aged children and adolescents include unintentional and intentional injury. Unintentional injury includes injuries from motor vehicle crashes, pedestrian and cycling collisions, falls, drowning, and burns, while intentional injury encompasses injury from violence directed at others and self-inflicted injury. In a national study of nonfatal injuries resulting in hospitalization, motor vehicle crashes accounted for 20% of injuries to children aged 13 to 15 years and 46% of injuries to older adolescents.' Gunshot wounds and stabbing made up 20% of injuries to children in both the 13-to 15-year age group and the 16-to 18-year-olds.' Each year, 30,000 children in the United States acquire a permanent disability due to injury. For children, pedestrian injuries, falls, and motor vehicle and bicycle injuries are most likely to
Background: Recent reports speculate that provider implicit attitudes about race may contribute t... more Background: Recent reports speculate that provider implicit attitudes about race may contribute to racial/ethnic health care disparities. Objectives: We hypothesized that implicit racial bias exists among pediatricians, implicit and explicit measures would differ and implicit measures may be related to quality of care. Research Design: A single-session, Web survey of academic pediatricians in an urban university measured implicit racial attitudes and stereotypes using a measure of implicit social cognition, the Implicit Association Test (IAT). Explicit (overt) attitudes were measured by self-report. Case vignettes were used to assess quality of care. Results: We found an implicit preference for European Americans relative to African Americans, which was weaker than implicit measures for others in society (mean IAT score ϭ 0.18; P ϭ 0.01; Cohen's d ϭ 0.41). Physicians held an implicit association between European Americans relative to African Americans and the concept of "compliant patient" (mean IAT score ϭ 0.25; P ϭ 0.001; Cohen's d ϭ 0.60) and for African Americans relative to European Americans and the concept of "preferred medical care" (mean IAT score ϭ Ϫ0.21; P ϭ 0.001; Cohen's d ϭ 0.64). Medical care differed by patient race in 1 of 4 case vignettes. No significant relationship was found between implicit and explicit measures, or implicit measures and treatment recommendations. Conclusions: Pediatricians held less implicit race bias compared with other MDs and others in society. Among pediatricians we found evidence of a moderate implicit "perceived patient compliance and race" stereotype. Further research is needed to explore whether physician implicit attitudes and stereotypes about race predict quality of care.
Purpose: Breast surgery comprises a significant portion of plastic surgery. Given the high volume... more Purpose: Breast surgery comprises a significant portion of plastic surgery. Given the high volume of breast surgery procedures, it is a significant area of investigation in plastic surgery literature. The aim of this study was to use established photogrammetric analysis techniques to evaluate the visual representation of racial diversity in the published breast surgery literature and to understand how it compares to the general and plastic surgery patient population.
Journal of Medical Education and Curricular Development
Objectives To describe the development and refinement of an implicit bias recognition and managem... more Objectives To describe the development and refinement of an implicit bias recognition and management training program for clinical trainees. Methods In the context of an NIH-funded clinical trial to address healthcare disparities in hypertension management, research and education faculty at an academic medical center used a participatory action research approach to engage local community members to develop and refine a “knowledge, awareness, and skill-building” bias recognition and mitigation program. The program targeted medical residents and Doctor of Nursing Practice students. The content of the two-session training included: didactics about healthcare disparities, racism and implicit bias; implicit association test (IAT) administration to raise awareness of personal implicit bias; skill building for bias-mitigating communication; and case scenarios for skill practice in simulation-based encounters with standardized patients (SPs) from the local community. Results The initial tri...
European Archives of Psychiatry and Clinical Neuroscience, 1999
Background: This paper focuses on the lifetime prevalence of mental disorders in individuals with... more Background: This paper focuses on the lifetime prevalence of mental disorders in individuals with Turkish migration backgrounds in Germany, as there is a lack of reliable epidemiological data on this subject. Methods: In total, 662 adults with Turkish migration backgrounds were interviewed in Hamburg and Berlin by trained, bilingual interviewers using the computerized Composite International Diagnostic Interview (CIDI DIA-X Version 2.8) to assess diagnoses according to the DSM-IVTR. Results: The analyses showed a weighted lifetime prevalence of 78.8% for any mental disorder, 21.6% for more than one and 7.3% for five or more disorders. Any mood disorder (41.9%), any anxiety disorder (35.7%) and any somatoform disorder/syndrome (33.7%) had the highest prevalences. Despite the sociodemographic differences between the first and second generations, there were no significant differences in the lifetime prevalence between generations, with the exception of any bipolar disorder. Female gender, older age and no current partnership were significantly associated with the occurrence of any mood disorder. Conclusions: Overall, the results indicate a high lifetime prevalence in individuals with Turkish migration backgrounds in Germany. These initial data are highly relevant to the German clinical and psychosocial healthcare system; however, the methodological limitations and potential biases should be considered when interpreting the results.
IntroductionFewer than half of internal medicine program directors report any health disparities ... more IntroductionFewer than half of internal medicine program directors report any health disparities curriculum. We piloted a web-based healthcare disparities module among internal medicine (IM) residents to test effectiveness and feasibility, compared to a convenient sample of graduate students enrolled in a public health equity course.MethodsIM residents participated in an in-person session (module 1: introduction to racial and ethnic health disparities), but first, they completed a pre-module knowledge quiz. Two weeks later, they completed module 2: “unconscious associations” and a post-module knowledge quiz. For the control arm Yale School of Public Health (YSPH) students enrolled in a course on health disparities completed the pre-module knowledge quiz, module 1, and 2 as required by their course instructor.ResultsForty-nine IM residents and 22 YSPH students completed the pre-module quiz and Module 1. The mean (SD) score out of 25 possible points for the IM residents on the pre-mod...
Bias toward historically marginalized patients affects patient-provider interactions and can lead... more Bias toward historically marginalized patients affects patient-provider interactions and can lead to lower quality of care and poor health outcomes for patients who are Black, Indigenous, People of Color (BIPOC) and Lesbian, Gay, Bisexual, Transgender and Gender Diverse (LGBTQ+). We gathered experiences with biased healthcare interactions and suggested solutions from 25 BIPOC and LGBTQ+ people. Through qualitative thematic analysis of interviews, we identified ten themes. Eight themes reflect the experience of bias: Transactional Care, Power Inequity, Communication Casualties, Bias-Embedded Medicine, System-level problems, Bigotry in Disguise, Fight or Flight, and The Aftermath. The remaining two themes reflect strategies for improving those experiences: Solutions and Good Experiences. Characterizing these themes and their interconnections is crucial to design effective informatics solutions that can address biases operating in clinical interactions with BIPOC and LGBTQ+ patients, improve the quality of patient-provider interactions, and ultimately promote health equity.
Journal of the American Medical Informatics Association
Objective People who experience marginalization, including Black, Indigenous, People of Color (BI... more Objective People who experience marginalization, including Black, Indigenous, People of Color (BIPOC) and Lesbian, Gay, Bisexual, Transgender, Queer, Plus (ie, all other marginalized genders and sexual orientations) people (LGBTQ+) experience discrimination during healthcare interactions, which negatively impacts patient–provider communication and care. Yet, scarce research examines the lived experience of unfair treatment among patients from marginalized groups to guide patient-centered tools that improve healthcare equity. Materials and Methods We interviewed 25 BIPOC and/or LGBTQ+ people about their experiences of unfair treatment and discrimination when visiting healthcare providers. Through thematic analysis, we describe participants’ immediate reactions and longer-term consequences of those experiences. Results We identified 4 ways that participants reacted to discrimination in the moment: Fighting, Fleeing, Excusing, and Working Around Bias. Long-term consequences reflect 6 w...
CHI Conference on Human Factors in Computing Systems Extended Abstracts
Although clinical training in implicit bias is essential for healthcare equity, major gaps remain... more Although clinical training in implicit bias is essential for healthcare equity, major gaps remain both for effective educational strategies and for tools to help identify implicit bias. To understand the perspectives of clinicians on the design of these needed strategies and tools, we conducted 21 semi-structured interviews with primary care clinicians about their perspectives and design recommendations for tools to improve patient-centered communication and to help mitigate implicit bias. Participants generated three types of solutions to improve communication and raise awareness of implicit bias: digital nudges, guided reflection, and data-driven feedback. Given the nuance of implicit bias communication feedback, these findings illustrate innovative design directions for communication training strategies that clinicians may find acceptable. Improving communication skills through individual feedback designed by clinicians for clinicians has the potential to improve healthcare equity.
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