Racial/Gender Biases in Student Clinical Decision-Making: a Mixed-Method Study of Medical School Attributes Associated with Lower Incidence of Biases.

BACKGROUND: Accumulating evidence suggests that clinician racial/gender decision-making biases in some instances contribute to health disparities. Previous work has produced evidence of such biases in medical students. OBJECTIVE: To identify contextual attributes in medical schools associated on average with low levels of racial/gender clinical decision-making biases. DESIGN: A mixed-method design using comparison case studies of 15 medical schools selected based on results of a previous survey of student decision-making bias: 7 schools whose students collectively had, and 8 schools whose students had not shown evidence of such biases. PARTICIPANTS: Purposively sampled faculty, staff, underrepresented minority medical students, and clinical-level medical students at each school. MAIN MEASURES: Quantitative descriptive data and qualitative interview and focus group data assessing 32 school attributes theorized in the literature to be associated with formation of decision-making and biases. We used a mixed-method analytic design with standard qualitative analysis and fuzzy set qualitative comparative analysis. KEY RESULTS: Across the 15 schools, a total of 104 faculty, administrators and staff and 21 students participated in individual interviews, and 196 students participated in 29 focus groups. While no single attribute or group of attributes distinguished the two clusters of schools, analysis showed some contextual attributes were seen more commonly in schools whose students had not demonstrated biases: longitudinal reflective small group sessions; non-accusatory approach to training in diversity; longitudinal, integrated diversity curriculum; admissions priorities and action steps toward a diverse student body; and school service orientation to the community. CONCLUSIONS: We identified several potentially modifiable elements of the training environment that are more common in schools whose students do not show evidence of racial and gender biases.

Racial, gender, and socioeconomic status bias in senior medical student clinical decision-making: a national survey.

BACKGROUND: Research suggests stereotyping by clinicians as one contributor to racial and gender-based health disparities. It is necessary to understand the origins of such biases before interventions can be developed to eliminate them. As a first step toward this understanding, we tested for the presence of bias in senior medical students. OBJECTIVE: The purpose of the study was to determine whether bias based on race, gender, or socioeconomic status influenced clinical decision-making among medical students. DESIGN: We surveyed seniors at 84 medical schools, who were required to choose between two clinically equivalent management options for a set of cardiac patient vignettes. We examined variations in student recommendations based on patient race, gender, and socioeconomic status. PARTICIPANTS: The study included senior medical students. MAIN MEASURES: We investigated the percentage of students selecting cardiac procedural options for vignette patients, analyzed by patient race, gender, and socioeconomic status. KEY RESULTS: Among 4,603 returned surveys, we found no evidence in the overall sample supporting racial or gender bias in student clinical decision-making. Students were slightly more likely to recommend cardiac procedural options for black (43.9 %) vs. white (42 %, p = .03) patients; there was no difference by patient gender. Patient socioeconomic status was the strongest predictor of student recommendations, with patients described as having the highest socioeconomic status most likely to receive procedural care recommendations (50.3 % vs. 43.2 % for those in the lowest socioeconomic status group, p < .001). Analysis by subgroup, however, showed significant regional geographic variation in the influence of patient race and gender on decision-making. Multilevel analysis showed that white female patients were least likely to receive procedural recommendations. CONCLUSIONS: In the sample as a whole, we found no evidence of racial or gender bias in student clinical decision-making. However, we did find evidence of bias with regard to the influence of patient socioeconomic status, geographic variations, and the influence of interactions between patient race and gender on student recommendations.

Costs and inconsistencies in US IRB review of low-risk medical education research.

CONTEXT: Advances in communication technologies over the last two decades have transformed the way medical education research is conducted, creating opportunities for multi-institution national and international studies. Although these studies enable researchers to gain broader understandings of educational processes across institutions, they increase the need for multiple institutional review board (IRB) reviews to ensure the protection of human subjects. OBJECTIVES: This study describes the process of obtaining multiple IRB approvals of the same protocol for a multi-site, low-risk, medical education research project in the USA. The burden of obtaining those reviews and their consistency are assessed. The associated time and costs, and implications for the research process are detailed. METHODS: Following review by the investigators' parent institution IRB, the project team circulated a uniform protocol for conduct of a low-risk, medical education survey to the IRBs of 89 US medical schools for review. The processes and time required to obtain approvals were recorded to estimate associated research team personnel costs. RESULTS: Approval could not be obtained from five IRBs as a result of insurmountable procedural barriers. A total of 67 IRBs eventually deferred to the parent IRB determination. The remaining IRBs required a variety of additional procedural processes before ultimately agreeing with the original determination. The personnel costs associated with obtaining the 84 approvals amounted to US$121,344. CONCLUSIONS: Considering the value of multi-site designs to address a range of research questions, enhance participant diversity and develop representative findings, solutions must be found to counter inefficiencies of current IRB review processes for low-risk research, such as that usually conducted in medical education. Although we acknowledge that local review is an essential protective measure for research involving identifiable communities that are uniquely susceptible to social or economic harm, this report suggests that proposals to modernise and streamline IRB review processes for low-risk research are timely and relevant.

Cultivating a cycle of trust with diverse communities in practice-based research: a report from PRIME Net.

PURPOSE: Practice-based research networks (PBRNs) are increasingly seen as important vehicles to translate research into practice, although less is known about the process of engaging diverse communities in PBRN research. The objective of this study was to identify strategies for successfully recruiting and retaining diverse racial/ethnic communities into PBRN research studies. METHODS: This collaborative, multisite study engaged 5 of the 8 networks of the PRImary care MultiEthnic Network (PRIME Net) consortium that conducts research with traditionally underrepresented/underserved populations. We used a sequential, qualitative research design. We first conducted 1 key informant interview with each of 24 researchers experienced in recruiting research participants from 5 racial/ethnic communities (African American, Arab/Chaldean, Chinese, Hispanic, and Native American). Subsequently, we conducted 18 focus groups with 172 persons from these communities. RESULTS: Participants' comments indicated that successful recruitment and retention of underrepresented populations in PBRN studies is linked to the overall research process. This process, which we termed the cycle of trust, entailed developing and sustaining relationships of trust during 4 interrelated stages: before the study, during study recruitment, throughout study conduct, and after study completion. Participants identified a set of flexible strategies within each stage and called for close engagement with clinic and community partners. CONCLUSIONS: Our participants suggest that approaches to research that lay a foundation of trust, demonstrate respect for community members, and extend beyond the enrollment and data collection phases are essential to enhance the participation of diverse populations in PBRN research. These findings offer the PBRN community a guide toward achieving this important goal.

Three-dimensional static modeling of the lumbar spine.

This paper presents three-dimensional static modeling of the human lumbar spine to be used in the formation of anatomically-correct movement patterns for a fully cable-actuated robotic lumbar spine which can mimic in vivo human lumbar spine movements to provide better hands-on training for medical students. The mathematical model incorporates five lumbar vertebrae between the first lumbar vertebra and the sacrum, with dimensions of an average adult human spine. The vertebrae are connected to each other by elastic elements, torsional springs and a spherical joint located at the inferoposterior corner in the mid-sagittal plane of the vertebral body. Elastic elements represent the ligaments that surround the facet joints and the torsional springs represent the collective effect of intervertebral disc which plays a major role in balancing torsional load during upper body motion and the remaining ligaments that support the spinal column. The elastic elements and torsional springs are considered to be nonlinear. The nonlinear stiffness constants for six motion types were solved using a multiobjective optimization technique. The quantitative comparison between the angles of rotations predicted by the proposed model and in the experimental data confirmed that the model yields angles of rotation close to the experimental data. The main contribution is that the new model can be used for all motions while the experimental data was only obtained at discrete measurement points.

Climate change and population growth in Timor Leste: implications for food security.

The climate in Timor Leste (East Timor) is predicted to become about 1.5 °C warmer and about 10 % wetter on average by 2050. By the same year, the population is expected to triple from 1 to 2.5-3 million. This article maps the predicted changes in temperature and rainfall and reviews the implications of climate change and population growth on agricultural systems. Improved cultivars of maize, rice, cassava, sweet potato and peanuts with high yield performance have been introduced, but these will need to be augmented in the future with better adapted cultivars and new crops, such as food and fodder legumes and new management practices. The requirements for fertilizers to boost yields and terracing and/or contour hedgerows to prevent soil erosion of steeply sloping terrain are discussed. Contour hedges can also be used for fodder for improved animal production to provide protein to reduce malnutrition.

A Comparative Case Study Analysis of Cultural Competence Training at 15 U.S. Medical Schools.

PURPOSE: Twenty years have passed since the Liaison Committee on Medical Education (LCME) mandated cultural competence training at U.S. medical schools. There remain multiple challenges to implementation of this training, including curricular constraints, varying interpretations of cultural competence, and evidence supporting the efficacy of such training. This study explored how medical schools have worked to implement cultural competence training. METHOD: Fifteen regionally diverse public and private U.S. medical schools participated in the study. In 2012-2014, the authors conducted 125 interviews with 52 administrators, 51 faculty or staff members, and 22 third- and fourth-year medical students, along with 29 focus groups with an additional 196 medical students. Interviews were recorded, transcribed, and imported into NVivo 10 software for qualitative data analysis. Queries captured topics related to students' preparedness to work with diverse patients, engagement with sociocultural issues, and general perception of preclinical and clinical curricula. RESULTS: Three thematic areas emerged regarding cultural competence training: formal curriculum, conditions of teaching, and institutional commitment. At the formal curricular level, schools offered a range of courses collectively emphasizing communication skills, patient-centered care, and community-based projects. Conditions of teaching emphasized integration of cultural competence into the preclinical years and reflection on the delivery of content. At the institutional level, commitment to institutional diversity, development of programs, and degree of prioritization of cultural competence varied. CONCLUSIONS: There is variation in how medical schools approach cultural competence. Among the 15 participating schools, longitudinal and experiential learning emerged as important, highlighting the needs beyond mere integration of cultural competence content into the formal curriculum. To determine efficacy of cultural competence programming, it is critical to conduct systematic assessment to identify and address gaps. While LCME standards have transformed aspects of medical education, further research is needed to clarify evidence-based, effective approaches to this training.

Ethics of health research in communities: perspectives from the southwestern United States.

PURPOSE: The increasing attention paid to community-based research highlights the question of whether human research protections focused on the individual are adequate to safeguard communities. We conducted a study to explore how community members perceive low-risk health research, the adequacy of human research protection processes, and the ethical conduct of community-based research. METHODS: Eighteen focus groups were conducted among rural and urban Hispanic and Native American communities in New Mexico using a semistructured guide. Group transcriptions were analyzed using iterative readings and coding, with review of the analytic summary by group members. RESULTS: Although participants recognized the value of health research, many also identified several adverse effects of research in their communities, including social (community and individual labeling, stigmatization, and discrimination) and economic (community job losses, increased insurance rates, and loss of community income). A lack of community beneficence was emphasized by participants who spoke of researchers who fail to communicate results adequately or assist with follow-through. Many group members did not believe current human research and data privacy processes were adequate to protect or assist communities. CONCLUSIONS: Ethical review of community-based health research should apply the Belmont principles to communities. Researchers should adopt additional approaches to community-based research by engaging communities as active partners throughout the research process, focusing on community priorities, and taking extra precautions to assure individual and community privacy. Plans for meaningful dissemination of results to communities should be part of the research design.

Can we rapidly identify traditional, complementary and alternative medicine users in the primary care encounter? A RIOS Net study.

OBJECTIVE: Pressed for time to address competing clinical demands within the brief clinical encounter, primary care clinicians often rely on observations of patients to select topics to address. Use of traditional, complementary, or alternative medicine (TM/CAM) may be an important topic for discussion with a patient, but identification of patients using TM/CAM is problematic. We conducted this study to determine if observable characteristics--among southwestern Hispanic and Native American persons--might suggest to the clinician that a patient is likely to use TM/CAM. DESIGN: A combination of clinic staff focus groups, patient and clinician interviews, and a clinician focus group was used to explore possible predictors of TM/CAM use among primary care patients in practices serving predominantly Hispanic and Native American communities. RESULTS: No easily observable characteristics were identified that clinicians might use to predict TM/CAM use in their patients. Less readily observable characteristics--identification with culture, family of origin, health condition--were more likely to be associated with TM/CAM use, but not infallibly so. CONCLUSIONS: Rather than attempt to predict TM/CAM use by an individual patient, clinicians may be better served by assuming its use by all, by applying strategies for rapid and effective communications with patients about the topic, by selecting which patients to discuss TM/CAM use with based on clinical circumstances, and/or by gathering information about TM/CAM use as part of routine initial database development.

'They don't ask me so I don't tell them': patient-clinician communication about traditional, complementary, and alternative medicine.

PURPOSE: Although high rates of traditional medicine and complementary and alternative medicine (TM/CAM) use have been well documented, there has been less attention to the factors influencing communication between patients and their primary care clinicians about TM/CAM. Such communication can be important in anticipating possible drug-herb interactions and in assuring agreement about therapeutic plans. METHODS: We used sequential, multistage, qualitative methods, including focus groups, in-depth interviews, and a video vignette, to explore communication about TM/CAM between patients and their primary care clinicians. The study was conducted in RIOS Net (Research Involved in Outpatient Settings Network), a Southwestern US practice-based research network, situated largely in Hispanic and American Indian communities where TM/CAM is an important part of self-care. RESULTS: One hundred fourteen patients, 41 clinic staff members, and 19 primary care clinicians in 8 clinic sites participated. The degree and nature of TM/ CAM communication is based on certain conditions in the clinical encounter. We categorized these findings into 3 themes: acceptance/nonjudgment, initiation of communication, and safety/efficacy. Perceived clinician receptivity to and initiation of discussion about TM/CAM strongly influenced patients' decisions to communicate; perceived clinician expertise in TM/CAM was less important. Clinicians' comfort with patients' self-care approaches and their level of concern about lack of scientific evidence of effectiveness and safety of TM/CAM influenced their communication about TM/CAM with patients. CONCLUSIONS: Specific communication barriers limit patient-clinician communication about TM/CAM. Clinicians who wish to communicate more effectively with their patients about these topics and better integrate the types of care their patients use can change the communication dynamic with simple strategies designed to overcome these barriers.

Combining web-based and mail surveys improves response rates: a PBRN study from PRIME Net.

PURPOSE: The advent of Web-based survey tools has provided the investigator with an alternative to paper-based survey methods that in many instances may be less expensive to implement than traditional paper-based surveys. Newer technology, however, does not diminish the importance of obtaining an adequate response rate. METHODS: We analyzed response rate data obtained from a survey implemented across 3 practice-based research networks (PBRNs) in which the survey was first implemented electronically with 5 rounds of electronic solicitation for an Internet-based questionnaire and then by 2 rounds of a paper-based version mailed only to nonresponders. RESULTS: Overall, 24% of the total survey responses received were in the paper mode despite intense promotion of the survey in the electronic phase. CONCLUSIONS: Our results suggest there is still an important role for the use of paper-based methods in PBRN survey research. Both hard copy and electronic survey collection methods may be required to enhance clinician response rates in PBRNs.

Cadexomer iodine: an effective palliative dressing in chronic critical limb ischemia.

UNLABELLED: Cadexomer iodine (CI) was evaluated as a palliative wound care dressing for foot ulcers in chronic critical limb ischemia (CCLI) given its ability to prevent infection and absorb moisture. METHODS: A retrospective study of 11 patients with CCLI and wounds on distal lower extremities that were treated with cadexomer iodine. The product was applied topically on a daily basis. Wounds were debrided cautiously to minimize blood loss. Patients were monitored in the clinic on a weekly to biweekly basis. RESULTS: Seven patients in this cohort had all or some wounds on their feet close, at least temporarily. Two patients ultimately underwent proximal amputations, but the procedures were delayed 9 months in one patient, and 3 years in the other. Ischemic wounds of 3 patients were stabilized with CI allowing time for invasive revascularization followed by successful distal amputations resulting in ongoing limb salvage of 5 months to almost 4 years. Four patients currently being treated with CI have avoided proximal amputations for 4-18 months. CONCLUSION: Cadexomer iodine is an effective palliative dressing for wounds in CCLI. The antimicrobial effect of iodine prevents wet gangrene. The absorptive capacity of cadexomer beads dries necrotic tissue facilitating dry gangrene and auto-amputation without desiccating viable tissue. Cadexomer iodine enhances autolytic debridement, mitigates inflammation beyond the antimicrobial effects of iodine, and encourages granulation and epithelialization even in severely hypoperfused wounds. Cadexomer iodine delays proximal limb amputation in CCLI and may facilitate healing in some ischemic wounds.

Social capital and health care experiences among low-income individuals.

OBJECTIVES: We examined relationships between social capital and health service measures among low-income individuals and assessed the psychometric properties of a theory-based measure of social capital. METHODS: We conducted a statewide telephone survey of 1216 low-income New Mexico residents. Respondents reported on barriers to health care access, use of health care services, satisfaction with care, and quality of provider communication and answered questions focusing on social capital. RESULTS: The social capital measure demonstrated strong psychometric properties. Regression analyses showed that some but not all components of social capital were related to measures of health services; for example, social support was inversely related to barriers to care (odds ratio=0.73; 95% confidence interval=0.59, 0.92). CONCLUSIONS: Social capital is a complex concept, with some elements appearing to be related to individuals' experiences with health services. More research is needed to refine social capital theory and to clarify the contributions of social capital versus structural factors (e.g., insurance coverage and income) to health care experiences.

The virtual haptic back: a simulation for training in palpatory diagnosis.

BACKGROUND: Models and simulations are finding increased roles in medical education. The Virtual Haptic Back (VHB) is a virtual reality simulation of the mechanical properties of the human back designed as an aid to teaching clinical palpatory diagnosis. METHODS: Eighty-nine first year medical students of the Ohio University College of Osteopathic Medicine carried out six, 15-minute practice sessions with the VHB, plus tests before and after the sessions in order to monitor progress in identifying regions of simulated abnormal tissue compliance. Students palpated with two digits, fingers or thumbs, by placing them in gimbaled thimbles at the ends of PHANToM 3.0(R) haptic interface arms. The interface simulated the contours and compliance of the back surface by the action of electric motors. The motors limited the compression of the virtual tissues induced by the palpating fingers, by generating counterforces. Users could see the position of their fingers with respect to the back on a video monitor just behind the plane of the haptic back. The abnormal region varied randomly among 12 locations between trials. During the practice sessions student users received immediate feedback following each trial, indicating either a correct choice or the actual location of the abnormality if an incorrect choice had been made. This allowed the user to feel the actual abnormality before going on to the next trial. Changes in accuracy, speed and Weber fraction across practice sessions were analyzed using a repeated measures analysis of variance. RESULTS: Students improved in accuracy and speed of diagnosis with practice. The smallest difference in simulated tissue compliance users were able to detect improved from 28% (SD = 9.5%) to 14% (SD = 4.4%) during the practice sessions while average detection time decreased from 39 (SD = 19.8) to 17 (SD = 11.7) seconds. When asked in anonymous evaluation questionnaires if they judged the VHB practice to be helpful to them in the clinical palpation and manual medicine laboratory, 41% said yes, 51% said maybe, and 8% said no. CONCLUSION: The VHB has potential value as a teaching aid for students in the initial phases of learning palpatory diagnosis.

Repeated palpatory training of medical students on the Virtual Haptic Back.

The effectiveness of simulation-based training has been accepted with great success in many fields including medicine. Most of the simulation research and development in medicine has focused on surgery. There has been some development of hardware based biomechanical models of sections of human anatomy, such as pelvic exam simulators. More recently, with the advances in haptics technology, software and hardware based simulators are being developed for the previously ignored area of palpatory diagnosis. The Virtual Haptic Back (VHB) is a simulator based on virtual reality and haptics that is currently being used to train medical students in palpatory diagnosis. This study examined the effect of repeating the training on the VHB.

Moving Away from the Tip of the Pyramid: Screening and Brief Intervention for Risky Alcohol and Opioid Use in Underserved Patients.

PURPOSE: Rates of risky substance use and substance use disorders are high in primary-care practices, yet the adoption of universal screening and brief intervention (SBI) has been slow and uneven. This study aimed to describe SBI-related attitudes, practices, and perspectives regarding practice change among medical providers in a minority-majority state. METHODS: We conducted a cross-sectional, on-line survey of a practice-based research network of medical providers serving predominantly Hispanic/Latinx and Native American patients in rural and urban settings. The main variables were clinician 1) perspectives on the need to address substance use problems in primary care, 2) current screening and intervention practices, and 3) satisfaction with and willingness to make changes to their practices. RESULTS: Although providers endorsed alcohol and opiate misuse to be significant problems in their practices, only 25% conducted universal screening. Providers reported focusing most of their screening efforts on those with substance use dependence. In general, providers rated importance of and ability to make practice changes moderately high. There was high interest in practice coordination with the community followed by interest in a collaborative care approach. CONCLUSIONS: Providers mainly focus efforts on the relatively few patients at the tip of the pyramid (substance use dependence) rather than on the majority of patients who comprise the middle of the pyramid (risky substance use). Practice change strategies are needed to increase universal screening with a focus on risky substance use, particularly in practices serving racial/ethnic communities.

Successful Utilization of Mechanical Thrombectomy in a Presentation of Pediatric Acute Ischemic Stroke.

Guidelines regarding the management of acute ischemic stroke (AIS) in the pediatric population using mechanical recanalization procedures are lacking. We present a case of a 14-year-old male diagnosed in the Emergency Department with an acute onset stroke who underwent successful mechanical clot removal by interventional radiology.

Obesity counseling and guidelines in primary care: a qualitative study.

BACKGROUND: The problem of obesity is now epidemic in the United States. Despite the existence of clinical guidelines for prevention and treatment of obesity and documented clinician concern about this problem, counseling for obesity reduction in primary care is infrequent. The principal aim of this study was to examine the views of clinicians on obesity counseling and to compare these views to the recommendations of leading obesity guidelines. METHODS: Twenty individual, in-depth interviews and two focus groups of clinicians serving predominantly low-income minority populations were conducted in a practice-based research network. Data were analyzed using immersion/crystallization and template approaches. RESULTS: Clinicians believe obesity is an important problem and report using mostly brief, targeted, low-intensity counseling in the face of limited patient motivation and lack of resources to support weight loss. They view family, cultural, social, and community factors as central to the problem of obesity, and their own efforts as generally ineffective. These clinicians similarly were unconvinced of the long-term effectiveness of any weight-loss strategies. CONCLUSIONS: Low levels of obesity counseling in primary care may reflect clinicians' self-assessment of their ineffectiveness in this area rather than lack of interest or knowledge. These clinicians perceive that obesity control efforts aimed at local community factors and environmental modifications are key strategies in augmenting and linking their efforts to successful outcomes.