Psychological reactance, misinformation, and distrust: A mixed methods analysis of COVID-19 vaccine uptake.

Background: Assessing perceptions of the COVID-19 vaccines is essential for understanding vaccine hesitancy and for improving uptake during public health emergencies. In the complicated landscape of COVID-19 vaccine mandates and rampant misinformation, many individuals faced challenges during vaccination decision-making. The purpose of our mixed methods study is to elucidate factors affecting vaccine decision-making and to highlight the discourse surrounding the COVID-19 vaccines in diverse and underserved communities. Methods: This mixed methods study was conducted in Arizona, Florida, Minnesota, and Wisconsin between March and November 2021, combining a cross-sectional survey (n = 3593) and focus groups (n = 47). Results: The groups least likely to report receiving a vaccination were non-Hispanic Whites, Indigenous people, males, and those with moderate socioeconomic status (SES). Those indicating high and low SES reported similar vaccination uptake. Focus group data highlighted resistance to mandates, distrust, misinformation, and concerns about the rapid development surrounding the COVID-19 vaccines. Psychological reactance theory posits that strongly persuasive messaging and social pressure can be perceived as a threat to freedom, encouraging an individual to take action to restore that freedom. Conclusion: Our findings indicate that a subsection of participants felt pressured to get the vaccine, which led to weaker intentions to vaccinate. These results suggest that vaccine rollout strategies should be reevaluated to improve and facilitate informed decision-making.

Comparisons of Explicit Weight Bias Across Common Clinical Specialties of US Resident Physicians.

BACKGROUND: Patients with high body weight are persistently stigmatized in medical settings, with studies demonstrating that providers endorse negative stereotypes of, and have lower regard for, higher-weight patients. Very little is known about how this weight bias varies across specialties. OBJECTIVE: The purpose of this study is to examine how explicit weight bias varies between resident providers among sixteen of the largest residency specialties in the USA. The identification of these differences will guide the prioritization and targeting of interventions. DESIGN: The current study utilized cross-sectional, observational data. PARTICIPANTS: Forty-nine allopathic medical schools were recruited to participate in this national, longitudinal study. The current study utilized data from 3267 trainees in Year 2 of Residency among those who specialized in one of the most common sixteen residency programs in 2016. MAIN MEASURES: Participants reported demographic information and residency specialties and completed three sets of measures pertaining to explicit weight bias. KEY RESULTS: A significant minority (13-48%) of residents reported slight-to-strong agreement with each anti-fat statement. There was a significant relationship between residency specialty and anti-fat blame (F(15, 3189 = 12.87, p < .001), η2 = .06), anti-fat dislike (F(15, 3189 = 7.01, p < .001), η2 = .03), and attitudes towards obese patients (F(15, 3208 = 17.78, p < .001), η2 = .08). Primary care residents (e.g., family medicine, pediatrics) consistently reported lower levels of weight bias than those in specialty programs (e.g., orthopedic surgery, anesthesiology). CONCLUSIONS: This study is the first to report on weight bias in a large, heterogeneous sample of US resident physicians. Problematic levels of weight bias were found in all specialties, with residents in specialty programs generally reporting more bias than those in primary care residencies. Future research should examine which factors contribute to these differences to guide intervention.

The impact of neighborhoods and friendships on interracial anxiety among medical students and residents: A report from the medical student CHANGES study.

OBJECTIVE: To examine the experience of interracial anxiety among health professionals and how it may affect the quality of their interactions with patients from racially marginalized populations. We explored the influence of prior interracial exposure-specifically through childhood neighborhoods, college student bodies, and friend groups-on interracial anxiety among medical students and residents. We also examined whether levels of interracial anxiety change from medical school through residency. DATA SOURCE: Web-based longitudinal survey data from the Medical Student Cognitive Habits and Growth Evaluation Study. STUDY DESIGN: We used a retrospective longitudinal design with four observations for each trainee. The study population consisted of non-Black US medical trainees surveyed in their 1st and 4th years of medical school and 2nd and 3rd years of residency. Mixed effects longitudinal models were used to assess predictors of interracial anxiety and assess changes in interracial anxiety scores over time. PRINCIPAL FINDINGS: In total, 3155 non-Black medical trainees were followed for 7 years. Seventy-eight percent grew up in predominantly White neighborhoods. Living in predominantly White neighborhoods and having less racially diverse friends were associated with higher levels of interracial anxiety among medical trainees. Trainees' interracial anxiety scores did not substantially change over time; interracial anxiety was highest in the 1st year of medical school, lowest in the 4th year, and increased slightly during residency. CONCLUSIONS: Neighborhood and friend group composition had independent effects on interracial anxiety, indicating that premedical racial socialization may affect medical trainees' preparedness to interact effectively with diverse patient populations. Additionally, the lack of substantial change in interracial anxiety throughout medical training suggests the importance of providing curricular tools and structure (e.g., instituting interracial cooperative learning activities) to foster the development of healthy interracial relationships.

Patient perceptions of body mass index restrictions limiting fertility care for women with high body mass index.

RESEARCH QUESTION: What is the patient experience of women with high body mass index (BMI) with BMI restrictions that limit fertility care? DESIGN: Qualitative study using in-depth, semi-structured interview methodology. Interview transcripts were analysed for iterative themes in accordance with principles of grounded theory. RESULTS: Forty women with a BMI of 35 kg/m2 or higher with scheduled or completed appointment at the Reproductive Endocrinology and Infertility (REI) clinic completed an interview. Most participants experienced BMI restrictions as unjust. Many perceived that BMI restrictions on fertility care may be medically justified and were in support of weight loss discussions to improve chances of pregnancy; however, several argued that they should have autonomy to commence treatment following an individualized risk assessment. Participants offered recommendations to improve discussion of BMI restrictions and weight loss, including framing the conversation as supportive of their reproductive goals and offering proactive referral to weight loss support to prevent the perception that BMI is a categorical exclusion to future fertility care. CONCLUSIONS: Participant experiences highlight a need for enhanced strategies for communicating BMI restrictions and weight loss recommendations in ways that are perceived to be supportive of patients' fertility goals without further contributing to weight bias and stigma experienced in medical settings. Opportunities for training to mitigate experiences of weight stigma may be beneficial for clinical and non-clinical staff. Evaluation of BMI policies should be undertaken within the context of clinic policies that permit or prohibit fertility care for other high-risk groups.

Dismantling weight stigma in eating disorder treatment: Next steps for the field.

The authors posit current guidelines and treatment for eating disorders (EDs) fail to adequately address, and often perpetuate, weight stigma. The social devaluation and denigration of higher-weight individuals cuts across nearly every life domain and is associated with negative physiological and psychosocial outcomes, mirroring the harms attributed to weight itself. Maintaining focus on weight in ED treatment can intensify weight stigma among patients and providers, leading to increased internalization, shame, and poorer health outcomes. Stigma has been recognized as a fundamental cause of health inequities. With no clear evidence that the proposed mechanisms of ED treatment effectively address internalized weight bias and its association with disordered eating behavior, it is not hard to imagine that providers' perpetuation of weight bias, however unintentional, may be a key contributor to the suboptimal response to ED treatment. Several reported examples of weight stigma in ED treatment are discussed to illustrate the pervasiveness and insidiousness of this problem. The authors contend weight management inherently perpetuates weight stigma and outline steps for researchers and providers to promote weight-inclusive care (targeting health behavior change rather than weight itself) as an alternative approach capable of addressing some of the many social injustices in the history of this field.

Patient and Health Care Professional Perspectives on Stigma in Integrated Behavioral Health: Barriers and Recommendations.

PURPOSE: Stigma related to mental health is well documented and a major barrier to using mental and physical health care. Integrated behavioral health (IBH) in primary care, in which behavioral/mental health care services are located within a primary care setting, may reduce the experience of stigma. The purpose of this study was to assess the opinions of patients and health care professionals about mental illness stigma as a barrier to engagement with IBH and to gain insight into strategies to reduce stigma, encourage discussion of mental health, and increase uptake of IBH care. METHODS: We conducted semistructured interviews with 16 patients referred to IBH in a prior year and 15 health care professionals (12 primary care physicians and 3 psychologists). Interviews were transcribed and inductively coded separately by 2 coders for common themes and subthemes under the topic headings of barriers, facilitators, and recommendations. RESULTS: We identified 10 converging themes from interviews with patients and the health care professionals, representing important complementary perspectives, with respect to barriers, facilitators, and recommendations. Barriers included professionals, families, and the public as sources of stigma, as well as self-stigma or avoidance, or internalizing negative stereotypes. Facilitators and recommendations included normalizing discussion of mental health and mental health care-seeking action, using patient-centered and empathetic communication strategies, sharing by health care professionals of their own experiences, and tailoring the discussion of mental health to patients' preferred understanding. CONCLUSIONS: Health care professionals can help reduce perceptions of stigma by having conversations with patients that normalize mental health discussion, use patient-centered communication, promote professional self-disclosure, and are tailored to patients' preferred understanding.

Patient Satisfaction Scores Impact Pediatrician Practice Patterns, Job Satisfaction, and Burnout.

Patient satisfaction (PS) surveying has become a commonly used measure of physician performance, but little is known about the impact on pediatricians. To investigate our hypothesis that PS surveys negatively impact pediatricians, we conducted a survey at an academic children's medical center. Of 155 eligible physicians, 115 responded (response rate 74%). Two-thirds (68%) did not find the PS score report useful and 88% did not feel that PS scores accurately reflect the physician's clinical ability. A third reported ordering tests, medications, or consultations due to pressure for higher PS scores. In addition, one-third agreed that PS surveys contribute to burnout and make it difficult to practice meaningful medicine. Overall, PS score reporting has a negative impact on pediatricians, especially those who are female, BIPOC (Black, Indigenous, and People of color), subspecialists, younger, and attended non-US medical schools. Further investigation into improved methods for providing feedback to pediatric physicians is warranted.

The role of weight stigma in weight regain in bariatric surgery.

Obesity is highly stigmatized, and individuals who undergo bariatric surgery are subject not only to weight stigma, but also to stigma related to the procedure itself. Patients lost to follow-up after surgery make estimating the amount of regain occurring after surgery difficult, and often patients fail to follow up due the shame of weight regain. Patients report difficulty following the diet necessary to maintain weight loss. Additionally, when they seek support after surgery, they often encounter stigmatizing messaging related to weight. Weight bias internalization, weight stigma, and stigma about having the surgery all contribute to feelings of social isolation, disordered eating, and reduced motivation to engage in physical activity. In this chapter, we present evidence for the impact of stigma on bariatric surgery outcomes and discuss the behavioral, physiological, and emotional processes that contribute to weight regain.

Key Stakeholder Perspectives of Community Engagement Efforts and the Impact of the Covid-19 Pandemic.

INTRODUCTION: The COVID-19 pandemic has disproportionally affected historically marginalized populations and their access to resources and healthcare. In times of crisis, authentic community engagement is more important than ever. This study was Phase 1 of a larger 3-phase study to conduct timely community-engaged research with community members to understand the disproportionate impact of COVID-19 on historically underserved communities. The objective of this work was to conduct key informant (KI) interviews (1) to understand community organizations perspectives about the role that large academic health centers play as they interface with community organizations to support their work, (2) to leverage KI's expertise to identify needs and assets within the community, and (3) to inform both Phase 2 (focus group qualitative research) and Phase 3 (survey) of the broader study. METHODS: A total of 24 key informants were identified through purposeful sampling and one-on-one semi-structured interviews were conducted across 4 states using video conferencing. RESULTS: Barriers to access and lack of transparency were highlighted as major issues requiring reform-in particular, aggressive billing practices and insurance barriers exacerbated local distrust of medical institutions. KIs recognized the health institution's support for testing and vaccination during the COVID-19 pandemic, but noted other significant gaps in care, especially regarding mental health support. Although communication with the health institution was consistent for some KIs, others experienced unsustained communication efforts that hindered cooperation and relationship building. CONCLUSIONS: Leaders in the community as key stakeholders can provide unique insights into the challenges and potential solutions required to promote health equity, and foster understanding between local communities and healthcare institutions.

The Interplay Between Group Identity, Suicidality, and Bullying in Midwestern Middle School Youth, 18-42.

Bullying peaks in middle school and is a risk factor for negative mental health outcomes, including suicidality. Suicide rates are higher in nonmetropolitan/rural areas and for American Indian/Alaska Natives compared to other racial/ethnic groups. Stigma-related bullying, a type of interpersonal discrimination, is increasingly considered an important driver of peer victimization. This study centers on the group identity characteristics of race/ethnicity, weight status, and sex to explore how school-based and electronic-bullying victimization mediate suicidality amongst a cohort of middle school students in North Dakota. Bivariate, multivariate, and structural equation modeling were performed using data from the 2015 North Dakota Middle School Youth Risk Behavior Survey. Minoritized race/ethnicity, very overweight, and female students all experienced statistically higher suicidality than comparison groups, mediated in some instances by bullying. Group identity, stigma, and discrimination may influence suicidality in North Dakota middle school youth. More information is needed on stigma and discrimination, including intersections of identity, as drivers of bullying and suicidality in minoritized youth in nonmetropolitan/rural areas.

A model of weight-based stigma in health care and utilization outcomes: Evidence from the learning health systems network.

Objective: Obesity is stigmatized and people with obesity report experiencing stigmatizing situations when seeking health care. The implications of these experiences are not well understood. This study tests an indirect effects model of negative care experiences as an intermediate variable between obesity and care avoidance/utilization and switching primary care doctors. Methods: A survey was completed by 2380 primary care patients in the Learning Health Systems Network (LHSNet) Clinical Data Research Network with a BMI >25 kg/m2. Measures included scales assessing stigmatizing situations, perceived patient-centered communication, perceived respect, having delayed needed care, and having looked for a new primary doctor in the past 12 months. Sequential and serial indirect effects of care experiences and respect in the association between BMI and care utilization outcomes was modeled. Results: The hypothesized model was supported by findings. The associations between BMI and delaying needed care (OR = 1.06, p < 0.001) and attempting to switch primary doctors (OR = 1.02, p = 0.04) was mediated by both stigmatizing situations experienced in a health care context and lower patient-centered communication. Lower perceived respect mediated the association between care experiences and utilization outcomes. Conclusions: People with higher BMIs may avoid care or switch doctors as a result of stigmatizing experiences and poor communication with doctors. These outcomes may contribute to morbidity in people with obesity if they delay or avoid care for health concerns when symptoms first present.

Testing a Self-Affirmation Intervention for Improving the Psychosocial Health of Black and White Medical Students in the US.

Self-affirmation interventions have been shown to mitigate the negative psychological effects of stereotype threat on Black students in secondary and undergraduate education. However, there is currently limited research testing whether Black students in medical schools may also experience the negative influences of stereotype threat. Until now, it has been unclear whether Black (vs. White) students experience a lower sense of belonging in medical school and whether they can benefit from self-affirmation interventions during medical training. With a longitudinal field experiment, we tested (a) whether Black (vs. White) medical students in the US experience decrements in psychological well-being (i.e., fatigue, depression, anxiety), sense of belonging, perceived residency competitiveness, and residency goal stability; and (b) the extent to which a self-affirmation intervention would ameliorate any observed disparities in these outcomes for Black students. With a sample of 234 Black and 182 White medical students across 50 schools in the US, we found that Black students tended to report more fatigue and less belonging than White students; however, the self-affirmation intervention did not significantly influence students' fatigue, depression, anxiety, or belonging. Unexpectedly, Black students in the self-affirmation (vs. control) condition reported lower perceived competitiveness for residency. White students' perceived competitiveness for residency was unaffected by the intervention. Exploratory analyses revealed that Black (vs. White) students were less likely to indicate stable residency goals over time, which may be an indication of threat; however, this racial gap was eliminated with the intervention. We discuss the plausible reasons for these findings and provide recommendations for future work in this area.

A Longitudinal Study Exploring Learning Environment Culture and Subsequent Risk of Burnout Among Resident Physicians Overall and by Gender.

OBJECTIVE: To explore the relationship between learning environment culture and the subsequent risk of developing burnout in a national sample of residents overall and by gender. METHODS: From April 7 to August 2, 2016, and May 26 to August 5, 2017, we surveyed residents in their second (R2) and third (R3) postgraduate year. The survey included a negative interpersonal experiences scale (score range 1 to 7 points, higher being worse) assessing psychological safety and bias, inclusion, respect, and justice; an unfair treatment scale (score range 1 to 5 points, higher being worse), and two items from the Maslach Burnout Inventory. Individual responses to the R2 and R3 surveys were linked. RESULTS: The R2 survey was completed by 3588 of 4696 (76.4%) residents; 3058 of 3726 (82.1%) residents completed the R3 survey; and 2888 residents completed both surveys. Women reported more negative interpersonal experiences (mean [SD], 3.00 [0.83] vs 2.90 [0.85], P<.001) and unfair treatment (66.5% vs. 58.7%, P<.001) than men at R2. On multivariable analysis, women at R3 were more likely than their male counterparts to have burnout (odds ratio, 1.23; 95% CI, 1.02 to 1.48; P=.03). Both men and women who reported more negative interpersonal experiences at R2 were more likely to have burnout at R3 (odds ratio, 1.32; 95% CI, 1.14 to 1.52; P<.001). The factors contributing to burnout did not vary in effect magnitude by gender. CONCLUSION: These findings indicate women residents are more likely to have burnout relative to men in the third year of residency. Negative culture predicted subsequent burnout 1 year later among both men and women. Differences in burnout were at least partly due to differing levels of exposure to negative interactions for men versus women rather than a negative interaction having a differential impact on the well-being of men versus women.

Association between patients' body mass index and emergency department wait times: A multicenter observational cohort investigation by the reducing disparities increasing equity in emergency medicine (REDEEM) study group.

OBJECTIVE: Numerous studies have demonstrated evidence of obesity bias in healthcare settings, however, little is known about obesity bias in the Emergency Department (ED). The objective of this study was to investigate obesity bias in an ED setting by assessing the association between body mass index (BMI) and door-to-room (DTR) or door-to-provider (DTP) times among ED patients. METHODS: We conducted an observational cohort study of all adult patient (age ≥ 18 years of age) visits to 21 Mayo Clinic and Mayo Clinic Health System EDs between November 1, 2018 and March 31, 2020. We compared DTR and DTP times based on BMI category. RESULTS: We found that median DTR and DTP times for adults with class 3 obesity are significantly shorter than patients in the normal weight category. For men with class 3 obesity, median DTR and DTP times were 7.5% and 5.4% shorter than men in the normal weight category. Relative to women in the normal weight category, the median DTR and DTP times were 4.6% and 3.8% faster for women in obesity class 1, 4.9% and 5.1% faster for women in obesity class 2, and DTR was 4.4% faster for women in obesity class 3. These percentage differences translated to slightly shorter wait times of 0.4-1.2 min compared to median wait times for patients with normal BMI. CONCLUSION: We did not find evidence of longer wait times experienced by people with obesity. Rather, patients with obesity often experienced wait times that were shorter than patients of normal weight.

Associations Between Experience of Early Childhood Trauma and Impact on Obesity Status, Health, as Well as Perceptions of Obesity-Related Health Care.

OBJECTIVE: To evaluate the association between obesity and history of childhood trauma in an effort to define implications for the provider-patient relationship and possible causes of failure of obesity treatment. METHODS: Multisite survey developed by the Patient-Centered Outcomes Research Institute Learning Health Systems Obesity Cohort Workgroup consisting of 49 questions with 2 questions focusing on history of being a victim of childhood physical and/or sexual abuse was mailed to 19,964 overweight or obese patients. Data collection for this survey occurred from October 27, 2017, through March 1, 2018. RESULTS: Among the 2211 surveys included in analysis, respondents reporting being a victim of childhood abuse increased significantly with obesity (23.6%, 26.0%, 29.1%, and 36.8% for overweight, class I, class II, and class III obesity, respectively; P<.001). A higher percentage of those who reported being a victim of childhood abuse noted that their weight issues began at an earlier age (P=.002) and were more likely to have weight-related comorbidities (P<.001), even after controlling for body mass index. Impacting physician counseling on weight loss, patients who were childhood victims of abuse reported lower self-esteem (P<.001), were more likely to feel judged by their health care providers (P=.009), and less likely to feel being treated with respect (P=.045). CONCLUSION: Overall, being a victim of childhood abuse was significantly associated with obesity, lower self-esteem and negative experiences interacting with health care providers. Health care providers should receive training to ensure open and nonjudgmental visits with obese patients and consider the role of trauma survivorship issues in patients' development of obesity and health care experiences.

The role of weight bias and role-modeling in medical students' patient-centered communication with higher weight standardized patients.

OBJECTIVE: Patients with obesity may experience less patient-centered care. We assessed whether medical students' implicit/explicit weight-related attitudes and perceptions of normative attitudes are associated with patient-centered care for patients with obesity. METHODS: Third and fourth year medical students (N = 111) at one medical school completed a survey and participated in a patient care scenario with a standardized patient with obesity. Encounters were coded for patient-centered behavior. Predictors of patient-centered behaviors were assessed. RESULTS: Student perceptions that negative attitudes about patients with obesity are normative in medical school were significantly associated with poorer patient-centered behaviors, including lower attentiveness (b=-0.19, p = 0.01), friendliness (b=-0.28, p < 0.001), responsiveness (b=-0.21, p = 0.002), respectfulness (b=-0.17, p = 0.003), interactivity (b=-0.22, p = 0.003), likelihood of being recommended by observers (b=-0.34, p < 0.001), and patient-centeredness index scores (b=-0.16, p = 0.002). Student reported faculty role-modeling of discrimination against patients with obesity predicted lower friendliness (b=-0.16, p = 0.03), recommendation likelihood (b=-0.22, p = 0.04), and patient-centeredness index score (b=-0.12, p = 0.03). CONCLUSIONS: Negative normative attitudes and behaviors regarding obesity in the medical school environment may adversely influence the quality of patient-centered behaviors provided to patients with obesity. PRACTICE IMPLICATIONS: Efforts to improve patient-centered communication quality among medical trainees may benefit from intervention to improve group normative attitudes about patients with obesity.

Minority and low-income patients are less likely to have a scale for self-weighing in their home: A survey in primary care.

Daily self-weighing is a weight management behaviour that requires a scale; however, scale ownership may be cost-prohibitive for some patients. Our objective was to understand the proportion of primary care patients with a scale at home, and factors associated with home scale access, to potentially inform future interventions that facilitate scale access. Cross sectional survey of 216 adult patients from three primary care clinics: mixed-income urban/suburban (n = 68); mixed-income urban (n = 70); low-income urban (n = 74). The dependent variable was presence of a home scale; bivariate associations were conducted with variables including demographics, insurance type, clinic setting and self-reported height/weight. Mean age was 53 years; 71% women; 71% racial minority; mean body mass index 32 kg/m2 . Overall, 56% had a home scale. Most (79%) white patients owned a scale, compared to 46% of racial minority patients (P < .01); 33% of low-income patients owned scale, compared to over 66% of patients at the clinics serving mixed-income populations (P < .01). Most low-income urban clinic patients do not own a home scale. Because self-weighing is an effective weight-management behaviour, clinicians could consider assessing scale access, and future research should assess the health impact of providing scales to patients with overweight/obesity who desire weight loss or maintenance.

The Value of Interracial Contact for Reducing Anti-Black Bias Among Non-Black Physicians: A Cognitive Habits and Growth Evaluation (CHANGE) Study Report.

Although scholars have long studied circumstances that shape prejudice, inquiry into factors associated with long-term prejudice reduction has been more limited. Using a 6-year longitudinal study of non-Black physicians in training (N = 3,134), we examined the effect of three medical-school factors-interracial contact, medical-school environment, and diversity training-on explicit and implicit racial bias measured during medical residency. When accounting for all three factors, previous contact, and baseline bias, we found that quality of contact continued to predict lower explicit and implicit bias, although the effects were very small. Racial climate, modeling of bias, and hours of diversity training in medical school were not consistently related to less explicit or implicit bias during residency. These results highlight the benefits of interracial contact during an impactful experience such as medical school. Ultimately, professional institutions can play a role in reducing anti-Black bias by encouraging more frequent, and especially more favorable, interracial contact.

Contact and role modeling predict bias against lesbian and gay individuals among early-career physicians: A longitudinal study.

RATIONALE: Physician bias against sexual minorities can hinder the delivery of high-quality health care and thus contribute to the disproportionate prevalence of negative health outcomes within this population. Medical students' interpersonal experiences within the context of medical school may contribute to this bias. OBJECTIVE: The goal of the current research was to examine the relationship between these interpersonal experiences, reported by heterosexual, cisgender medical students, and explicit and implicit bias against lesbians and gay individuals, reported two years later during second year of medical residency. METHOD: Data were collected by surveying students (n = 2940) from a stratified sample of U.S. medical schools in fall 2010 (first semester of medical school), spring 2014 (final semester of medical school), and spring 2016 (second year of medical residency). RESULTS: Amount and favorability of contact with LGBT individuals, reported during the final semester of medical school, predicted lower levels of explicit bias against lesbian and gay individuals during second year of medical residency. Additionally, exposure to negative role modeling, also reported during the final semester of medical school, predicted higher levels of explicit bias against lesbian and gay individuals during second year of medical residency. Amount of contact with LGBT individuals - and in particular, with LGBT medical students - predicted lower levels of implicit bias against lesbian and gay individuals during second year of medical residency. Neither favorability of contact with LGBT individuals nor exposure to negative role modeling predicted implicit bias against lesbian and gay individuals during second year of medical residency. CONCLUSION: These results suggest that interpersonal experiences during medical school can systematically shape heterosexual, cisgender physicians' subsequent explicit and implicit bias against lesbian and gay individuals.