Faculty Bibliography

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: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.

Discrimination toward trainees is a pervasive problem, with surveys showing it is often perpetrated by patients. For several years, residents and faculty in an internal medicine residency have participated in a workshop offering a framework for responding to discriminatory behavior by patients. As part of a larger effort to reinforce this teaching and promote an inclusive environment, the authors pursued a multi-pronged simulation curriculum that could be incorporated into graduate medical education programs across their institution. First, the authors conducted trainee and faculty focus groups to better understand their experiences. Qualitative data was collected, including recommendations for responding to discrimination, characteristics of the most common experiences, and trainees' own ideas for worthwhile simulation scenarios. Trainees and faculty were then brought together in a collaborative process to co-develop simulation cases that were later implemented in curricula across multiple learner levels, specialties, and contexts. Participants in these simulations reported improved comfort in responding to discrimination in the moment and/or in the wake of such incidents. Through trainee-faculty collaboration, the project yielded authentic and impactful simulation experiences for learners, while also giving trainees an opportunity to turn previous trauma into constructive learning opportunities that promote an inclusive environment.

BACKGROUND:Anabolic androgenic steroids (AAS) are synthetic forms of testosterone frequently used as performance enhancing drugs among gay, bisexual, and queer (GBQ) men. Despite widespread use, associated harms, and the likely existence of an AAS use disorder, there is no medical consensus on standards of care for people who use AAS, with most medical providers focusing exclusively on abstinence. Individuals using AAS have developed community-based harm reduction strategies to mitigate these harms. METHODS:This paper is a sub-analysis of qualitative data obtained through semi-structured interviews with GBQ men using AAS for 8 or more weeks recruited through convenience and snowball sampling from clinical sites and LGBTQ + venues in New York City as well as through social media. Interviews were coded with themes developed using reflexive thematic analysis. Data related to harm reduction techniques were then re-analyzed through a prevention strategies framework lens of primary, secondary, and tertiary harm prevention. RESULTS:Thematic saturation was reached at twelve interviews in the primary analysis, with men reporting frequent use of multiple harm reduction techniques. For primary prevention, men avoided oral steroids and simultaneous substance use, tried to obtain AAS from reputable sources, used "cycling" to dose steroids, and practiced sterile injection techniques. Secondary prevention methods included patient-directed lab testing for hematocrit, liver and kidney function, cholesterol, prostate specific antigen, testosterone, and self-performed blood pressure checks. Tertiary prevention included donating blood and the use of medications without a prescription, including aromatase inhibitors, selective estrogen receptor blockers, aspirin, statins, angiotensin receptor blockers, clomiphene, and human chorionic gonadotropin. CONCLUSIONS:Despite many GBQ men experiencing harms from anabolic androgenic steroids, community members have often sought harm reduction techniques in lieu of abstinence. Though many of these techniques embrace clinical reasoning and may be more broadly applicable, additional research is needed to understand the impact of each intervention on the overall health of individuals using AAS.

Cisgender women and transgender men are less likely to be assessed for PrEP eligibility, prescribed PrEP, or retained in PrEP care. Thus, this pilot PrEP educational intervention was tailored for healthcare providers (HCPs) in obstetrics/gynecology who provide care to cisgender women and transgender men in an academically-affiliated, public hospital women's health clinic. The three-lecture educational curriculum designed for HCPs focused on PrEP eligibility and counseling, formulations and adherence, and prescription and payment assistance programs. Pre- and post-intervention surveys assessed HCP knowledge and barriers to PrEP counseling and prescription. Among n = 49 participants (mean age = 32.8 years; 85.7% cisgender women, mean years practicing = 4.2 years) pre-intervention, 8.7% had prior PrEP training and 61.2% felt very/somewhat uncomfortable prescribing PrEP. Post-intervention, knowledge of PrEP contraindications, eligibility, follow-up care, and assistance programs all increased. HCPs identified key barriers to PrEP care including lack of a dedicated PrEP navigator, culturally and linguistically appropriate patient materials on PrEP resources/costs, and PrEP-related content integrated into EHRs. Ongoing PrEP educational sessions can provide opportunities to practice PrEP counseling, including information on financial assistance. At the institutional level, incorporating PrEP screening in routine clinical practice via EMR prompts, facilitating PrEP medication monitoring, and enhancing telehealth for follow-up care could enhance PrEP prescription.

Little is known about how physician learners are assessed following educational interventions about providing gender-affirming care to transgender and gender diverse (TGD) people. The inclusion of learner assessments with educational interventions is essential to understand and measure health professionals' knowledge and skills. We seek to describe how the medical literature has approached the assessment of learners following educational interventions about TGD health. A scoping literature review was done. The guiding research question was "What are the current learner-assessment practices in medical education pedagogy about TGD health?" A total of 270 manuscripts were reviewed. 17 manuscripts were included for data extraction. Miller's pyramid was used to categorize results. 15 used pre- and post-intervention knowledge questionaries to assess learners. Six used simulated patient encounters to assess learners. Most assessments of TGD knowledge and skills among physician learners are pre- and post-surveys. There is sparse literature on higher level assessment following educational interventions that demonstrate learner skills, behaviors, or impact on patient outcomes. Discrete, one-time interventions that are lecture or workshop-based have yet to rigorously assess learners' ability to provide clinical care to TGD patients that is both culturally humble and clinically astute.

BACKGROUND:Sexual minority men (SMM) face severe health inequities alongside negative experiences that drive avoidance of medical care. Understanding how SMM experience healthcare is paramount to improving this population's health. Patient-centered care, which emphasizes mutual respect and collaboration between patients and providers, may alleviate the disparaging effects of the homophobia that SMM face in healthcare settings. OBJECTIVE:To explore how SMM perceive their experiences with healthcare providers and how care can most effectively meet their needs. DESIGN/METHODS:Semi-structured qualitative interviews focused on healthcare experiences, pre-exposure prophylaxis (PrEP), and HIV-related beliefs were conducted between July and November 2018. PARTICIPANTS/METHODS:The study included a sample of 43 young adult SMM (ages 25-27), representing diverse socioeconomic, racial, and ethnic backgrounds, in New York City. APPROACH/METHODS:Researchers utilized a multiphase, systematic coding method to identify salient themes in the interview transcripts. KEY RESULTS/RESULTS:Analyses revealed three main themes: (1) SMM perceived that their clinicians often lack adequate skills and knowledge required to provide care that considers participants' identities and behaviors; (2) SMM desired patient-centered care as a way to regain agency and actively participate in making decisions about their health; and (3) SMM felt that patient-centered care was more common with providers who were LGBTQ-affirming, including many who felt that this was especially true for LGBTQ-identified providers. CONCLUSIONS:SMM expressed a clear and strong desire for patient-centered approaches to care, often informed by experiences with healthcare providers who were unable to adequately meet their needs. However, widespread adoption of patient-centered care will require improving education and training for clinicians, with a focus on LGBTQ-specific clinical care and cultural humility. Through centering patients' preferences and experiences in the construction of care, patient-centered care can reduce health inequities among SMM and empower healthcare utilization in a population burdened by historic and ongoing stigmatization.

PURPOSE/OBJECTIVE:To characterize current lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI +) health-related undergraduate medical education (UME) curricular content and associated changes since a 2011 study and to determine the frequency and extent of institutional instruction in 17 LGBTQI + health-related topics, strategies for increasing LGBTQI + health-related content, and faculty development opportunities. METHOD/METHODS:Deans of medical education (or equivalent) at 214 allopathic or osteopathic medical schools in Canada and the United States were invited to complete a 36-question, Web-based questionnaire between June 2021 and September 2022. The main outcome measured was reported hours of LGBTQI + health-related curricular content. RESULTS:Of 214 schools, 100 (46.7%) responded, of which 85 (85.0%) fully completed the questionnaire. Compared to 5 median hours dedicated to LGBTQI + health-related in a 2011 study, the 2022 median reported time was 11 h (interquartile range [IQR], 6-16 h, p < 0.0001). Two UME institutions (2.4%; 95% CI, 0.0%-5.8%) reported 0 h during the pre-clerkship phase; 21 institutions (24.7%; CI, 15.5%-33.9%) reported 0 h during the clerkship phase; and 1 institution (1.2%; CI, 0%-3.5%) reported 0 h across the curriculum. Median US allopathic clerkship hours were significantly different from US osteopathic clerkship hours (4 h [IQR, 1-6 h] versus 0 h [IQR, 0-0 h]; p = 0.01). Suggested strategies to increase content included more curricular material focusing on LGBTQI + health and health disparities at 55 schools (64.7%; CI, 54.6%-74.9%), more faculty willing and able to teach LGBTQI + -related content at 49 schools (57.7%; CI, 47.1%-68.2%), and more evidence-based research on LGBTQI + health and health disparities at 24 schools (28.2%; CI, 18.7%-37.8%). CONCLUSION/CONCLUSIONS:Compared to a 2011 study, the median reported time dedicated to LGBTQI + health-related topics in 2022 increased across US and Canadian UME institutions, but the breadth, efficacy, or quality of instruction continued to vary substantially. Despite the increased hours, this still falls short of the number of hours based on recommended LGBTQI + health competencies from the Association of American Medical Colleges. While most deans of medical education reported their institutions' coverage of LGBTQI + health as 'fair,' 'good,' or 'very good,' there continues to be a call from UME leadership to increase curricular content. This requires dedicated training for faculty and students.

IMPORTANCE/UNASSIGNED:Anabolic androgenic steroids (AAS) are disproportionately used by sexual minority men, with the physical and mental health implications of AAS use incompletely understood. OBJECTIVE/UNASSIGNED:To understand the reasons for use and health care needs of gay, bisexual, and queer cisgender men using AAS. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This qualitative study was conducted from November 2021 to May 2023 using self-administered questionnaires and semistructured interviews that were transcribed and coded using reflexive thematic analysis. Participants were recruited through convenience and snowball sampling from lesbian, gay, bisexual, transgender, and queer clinical centers in New York, New York, as well as through online platforms. All patients self-identified as cisgender and gay, bisexual, or queer. EXPOSURES/UNASSIGNED:History of nonprescribed AAS use for a minimum of 8 consecutive weeks was required. MAIN OUTCOMES AND MEASURES/UNASSIGNED:The primary outcomes were reasons for and health implications of AAS use and interactions with health care practitioners, as determined through interviews. Interview transcripts were collected and analyzed. RESULTS/UNASSIGNED:Thematic saturation was reached after interviews with 12 male participants (mean [SD] age, 44 [11] years), with the majority of participants identifying as gay (10 participants [83%]), White non-Hispanic (9 participants [75%]), being in their 30s and 40s (9 participants [75%]), holding a bachelor's degree or higher (11 participants [92%]), and having used steroids for a mean (SD) of 7.5 (7.1) years. One participant (8%) self-identified as Black, and 2 (17%) identified as Hispanic. Seven men (58%) met the criteria for muscle dysmorphia on screening. Nine overarching themes were found, including internal and external motivators for initial use, continued use because of effectiveness or fear of losses, intensive personal research, physical and emotional harms experienced from use, using community-based harm reduction techniques, frustration with interactions with the medical community focused on AAS cessation, and concerns around the illegality of AAS. CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this qualitative study, AAS use among cisgender gay, bisexual, and queer men was found to be associated with multifactorial motivators, including a likely AAS use disorder and muscle dysmorphia. Despite all participants experiencing harms from use, men seeking medical help found insufficient support with practitioners insistent on AAS cessation and, thus, developed their own harm reduction techniques. Further research is needed to assess the utility of practitioner education efforts, the safety and efficacy of community-developed harm reduction methods, and the impact of AAS decriminalization on health care outcomes for this patient population.