Faculty Bibliography

OBJECTIVES/OBJECTIVE:Evidence for the impact of racial implicit bias and clinical reasoning remains conflicting. Our inability to characterize the relationship between racial implicit bias and clinical reasoning (CR) precludes development of comprehensive interventions seeking to address the impact of racial implicit bias on clinical encounters. To address this gap, we conducted a simulation-based investigation with clinical presentations with known health disparities, cognitive stressors common to clinical environments, and Black and White standardized patients (SPs). METHODS:We recruited 75 early-career generalist physicians from five academic medical centers in New York, NY, USA. Physicians engaged in a three-station simulation. The first was for level-setting, familiarizing physicians with the online platform. The second was a diagnostic dilemma - an atypical presentation of acute coronary syndrome (ACS). The third tested treatment decision-making in acute pain. Immediately afterward, physicians completed the Race Implicit Association Test (IAT) and Race Medical Cooperativeness (RMC) IAT measuring affective and cognitive implicit biases, respectively. Two investigators assessed CR accuracy by applying a scoring rubric to physicians' post-encounter notes. RESULTS:Statistical analyses revealed no significant correlations between physicians' Race-IAT scores and CR by SP race. However, for ACS, a moderate correlation was suggested between physicians' RMC-IAT scores and CR accuracy when seeing Black (R=0.36, CI -0.04 to 0.6), but not White, SPs (R=0.1, CI -0.44 to 0.24). CONCLUSIONS:This study expands our understanding of the complex impact of racial implicit bias on clinical encounters. Future, larger studies should explore affective and cognitive implicit biases' effects on CR across varied clinical scenarios and contexts with diverse SPs.

BACKGROUND:Health equity is receiving increased attention in medical education. However, guidance is often lacking on how to integrate health equity into routine medical education. Journal club presents an opportunity to deepen medical educators' and learners' understanding of health equity principles and use it as a lens through which to critically appraise the literature. AIM/OBJECTIVE:We present a health equity framework, iteratively co-created by faculty and learners, that can be applied in a journal club setting. SETTING/METHODS:Academic medical center in New York City, USA. PARTICIPANTS/METHODS:Faculty, residency program directors, medical students, and residents. PROGRAM DESCRIPTION/METHODS:Authors developed the health equity journal club framework during a medical student selective course. Learner and faculty applied the framework to journal club articles; their feedback informed revisions. Framework domains included authorship, ethics, methodology, language, peer review, and references. PROGRAM EVALUATION/RESULTS:Learner evaluations were overall positive, and 86% (n = 13) of responding residency program directors (n = 15) across 15 departments who were surveyed plan to use the framework moving forward. DISCUSSION/CONCLUSIONS:A health equity journal club framework applied to critical appraisal of the literature may facilitate health equity as a routine part of medical education. Co-creating the framework proved vital to inclusion of learner voices.

INTRODUCTION/BACKGROUND:Implicit bias can influence patient-clinician communication through clinician implicit bias (actual) or patients' perception of bias (perceived). Few curricula focus on skills to address implicit bias. We developed and evaluated a skills-based curriculum addressing implicit bias in clinical encounters. MATERIALS & METHODS/METHODS:A 60-minute session was delivered to 4 cohorts of learners (N = 458, ranging from first-year medical students to attendings) in academic medical settings. All had prior exposure to the topic of implicit bias. Instruction grounded in the Implicit Bias Recognition and Management framework described the impact of actual and perceived bias and patients' recommendations for restoring rapport once bias had impacted an encounter. Through audience response systems or role-plays with feedback, participants developed verbal procedures-personalized, verbatim statements to restore patient rapport when implicit bias has impacted an encounter. Learners submitted their verbal procedures online, which were then coded to identify helpful and unhelpful elements. Investigators coded verbal procedures and assigned point values for "helpful" and "unhelpful" elements resulting in scores from -1-6. RESULTS:Each approach yielded helpful elements. Overall, of submitted verbal procedures, 91.3 % were "helpful" and 8.6 % "unhelpful." Compared to audience response systems, verbal procedures developed through role-plays included significantly more "helpful" elements (2.21/1.29, p = 0.003 and 2.46/1.87 p = 0.009). CONCLUSIONS:Findings suggest learners can develop verbatim statements to restore rapport with patients in a single session if those learners have prior foundational knowledge about implicit bias and its relevance to healthcare disparities. PRACTICE IMPLICATIONS/CONCLUSIONS:Teaching verbal procedures could expand skill-building opportunities within implicit bias curricula.

OBJECTIVE:Racial implicit bias may contribute to health disparities in juvenile idiopathic arthritis (JIA) outcomes by impacting provider medical decision-making. Our study assessed racial and racial-medical compliance implicit biases of an international pediatric rheumatology community and investigated whether their biases impact treatment recommendations for patients with JIA. METHODS:A web-based survey, which included a randomized vignette describing either a White or Black patient with JIA, was sent to pediatric rheumatology providers. Participants were prompted to select the best patient management option and to complete two implicit association tests (IATs): race and race compliance. Student's t-tests or analysis of variance were used to compare IAT D-scores between or across groups; all tests were two-sided with P < 0.05 considered statistically significant. Logistic regression models were used to examine associations for two outcomes of interest: recommendation of either adequate (methotrexate monotherapy) or aggressive (methotrexate and adalimumab combination) treatment with each IAT D-score by each vignette. RESULTS:Overall, 165 pediatric rheumatologists completed the survey. Providers showed a slight pro-White bias in the race IAT (mean D-score ± SD 0.26 ± 0.5) and race-medical compliance IAT (mean D-score ± SD 0.16 ± 0.43). Although not statistically significant, a one-point increase in IAT D-scores was associated with a lower likelihood that providers would choose aggressive treatment versus adequate treatment in the Black vignette (odds ratio [OR] 0.55, 95% confidence interval [CI] 0.20-1.47; P = 0.23), and a greater likelihood that providers would choose aggressive treatment in the White vignette (OR 4.07, 95% CI 0.74-22.24; P = 0.11). CONCLUSION/CONCLUSIONS:Implicit bias was not associated with treatment recommendations. Further studies are needed to better evaluate the impact of implicit bias.

BACKGROUND:Graduate medical education (GME) on diversity, equity, and inclusion rarely teaches strategies for developing anti-racist mindsets and behaviors, and understanding of the impact of these programs and particular curricular components is lacking. OBJECTIVE:To evaluate the format, content, and impact of a longitudinal anti-racism conference series (ARC) on resident physicians within an urban internal medicine program through a qualitative analysis, with the goal of informing the development and implementation of other evidence-based anti-racism curricula in graduate medical education (GME). DESIGN/METHODS:The ARC consisted of eight mandatory, 60-min virtual conferences held between August 2020 and June 2021 within an internal medicine residency program's primary care track sub-group. The conference's content synthesized previous anti-racism curricula, scholarly readings, and practical experiences, and emphasized internal reflection and behavior change. PARTICIPANTS/METHODS:Thirty internal medicine resident physicians and six faculty members. MAIN MEASURES/METHODS:Seven voluntary, semi-structured, hour-long focus groups were conducted to document resident perspectives on the ARC's format, content, and impact of the curriculum on learner's professional and personal development. Constructivist grounded theory was used to analyze resident responses. KEY RESULTS/RESULTS:In total, 17/30 (57%) residents participated in focus groups. Analysis of course format, content, and impact revealed the following: (1) The most valued aspect of the course's instructional format was its perceived psychological safety. (2) Residents desired course content with more outward action steps than were offered. (3) Residents noted personal and professional impact across three main domains: intrapersonal, interpersonal, and institutional. CONCLUSIONS:In this longitudinal GME internal medicine anti-racism curriculum, participants felt that the curriculum format provided safe spaces to engage with topics on systemic racism and patient care, but content lacked sufficient action-oriented strategies. The curriculum's impact was multi-dimensional and could be studied more deeply in the future through simulation or direct observation.

BACKGROUND:Structured faculty development programs focused on integrating health equity into medical education curricula remain limited. AIM/OBJECTIVE:To describe an interdisciplinary faculty development program grounded in adult learning theory and to assess its impact on participants' professional growth. SETTING AND PARTICIPANTS/METHODS:Twenty-one faculty members across six academic-affiliated health systems. PROGRAM DESCRIPTION/METHODS:Fourteen 2-h monthly sessions were delivered over one full year. Course topics included health equity, adult learning theory, curriculum development, implicit bias, social determinants of health, racism, oppression, and collaborating with community partners. Educational strategies included reflections, small group discussions, logic models, and capstone development. PROGRAM EVALUATION/RESULTS:Using a Likert-type scale, participants rated all aspects of the program highly favorably, with median ratings ranging from 4 (agree) to 5 (strongly agree). Focus group results demonstrated that faculty experienced well-needed personal empowerment and professional growth in unexpected ways and identified several opportunities for programmatic growth. DISCUSSION/CONCLUSIONS:Program strengths included its interdisciplinary nature, creating a space to address isolation experienced by faculty working to advance health equity within their departments, advancement of skills to integrate health equity into their teaching contexts, and the opportunity for participants to envision their scholarship as part of a more extensive approach within the social determinants of health, health equity, and community health framework.

The Journal of General Internal Medicine (JGIM) has a long-standing history of publishing manuscripts focused on health equity and is committed to diversity, equity, and inclusion (DEI) in scientific writing and publishing. This is extremely important in the current climate where false narratives and attacks on DEI and health equity are rampant. To demonstrate their commitment to DEI and health equity, the JGIM Editors-in-Chief created an inaugural DEI Advocacy Team. Composed of four academic scholars with vast knowledge and expertise in health equity and DEI, the JGIM DEI Advocacy Team is posed to create the infrastructure for improving DEI in scientific writing and publishing within JGIM. The team strives to advocate for diversity among the editorial board and staff; foster an inclusive environment where all contributions are valued; and facilitate increased and equitable opportunities for publishing of scholarly work by underrepresented groups in medicine. To operationalize their goals, the JGIM DEI Advocacy Team created the 5TDEI Conceptual Framework (team, tools, tracking, transparency, training). This perspective provides a statement from the inaugural JGIM DEI Advocacy Team on how we envision promoting health equity, diversity, and inclusion in medical and scientific writing and publishing of research in JGIM.

BACKGROUND:Suboptimal support for colleagues experiencing discrimination can adversely impact clinician well-being and patient care. AIM/OBJECTIVE:To describe resident performance and experience during an Objective Structured Clinical Examination (OSCE) case centered on supporting a trainee facing discrimination to inform enhanced, supportive learning environments. SETTING/METHODS:Formative, internal medicine OSCE at a simulation center. PARTICIPANTS/METHODS:148 second-year residents across 2018, 2019, 2021, 2022. PROGRAM DESCRIPTION/METHODS:Residents had 10 min to support a Muslim standardized intern (SI) experiencing discrimination from a patient. The SI rated resident performance across Supervision, Relationship Development, and Support domains and provided written feedback. Post-OSCE evaluations elicited resident reflections on case challenges. PROGRAM EVALUATION/RESULTS:Proficient residents (≥ 80% average score across domains, n = 85) performed better in all items, except in not acting defensive and collaborating with SI to develop follow-up plan, compared to non-proficient residents (n = 65). The SI described effective approaches to feeling supported, including using empathetic statements, stating personal stance on discrimination, exhibiting supportive body language, and verbalizing support. Stating knowledge of situation upfront was an area of improvement. Residents found engaging the distressed SI difficult. DISCUSSION/CONCLUSIONS:Use of an explicit discrimination OSCE case can help identify effective approaches to supporting targets of discriminatory patients to inform future training.

BACKGROUND:Patients with disabilities face widespread barriers to accessing surgical care given inaccessible health systems, resulting in poor clinical outcomes and perpetuation of health inequities. One barrier is the lack of education, and therefore awareness, among trainees/providers, of the need for reasonable accommodations for surgical patients with disabilities. METHODS:We conducted a scoping review of the literature on the current state of disabilities curricula in medical education and graduate residency curriculum. RESULTS:While the literature does demonstrate a causal link between reasonable accommodation training and positive patient-provider relationships and improved clinical outcomes, in practice, disability-focused curricula are rare and often limited in time and to awareness-based didactic courses in medical education and surgical training. CONCLUSIONS:The absence of structured curricula to educate on anti-ableism and care for patients with disabilities promotes a system of structural "ableism." Expanding disability curricula for medical students and trainees may be an opportunity to intervene and promote better surgical care for all patients.