Using Causal Bayesian Networks to Assess the Role of Patient-Centered Care and Psychosocial Factors on Durable HIV Viral Suppression.

We assessed the role of patient-centered care on durable viral suppression (i.e., all viral load test results < 200 copies per ml during 2019) by conducting a retrospective cohort study of clients medically case managed by the Miami-Dade County Ryan White Program (RWP). Summary measures of patient-centered care practices of RWP-affiliated providers were obtained from a survey of 1352 clients. Bayesian network models analyzed the complex relationship between psychosocial and patient-centered care factors. Of 5037 clients, 4135 (82.1%) had durable viral suppression. Household income was the factor most strongly associated with durable viral suppression. Further, mean healthcare relationship score and mean "provider knows patient as a person" score were both associated with durable viral suppression. Healthcare relationship score moderated the association between low household income and lack of durable viral suppression. Although patient-centered care supports patient HIV care success, wrap around support is also needed for people with unmet psychosocial needs.

RESUMEN: Evaluamos el rol de la atención centrada en el paciente en la supresión viral duradera (es decir, todos los resultados de las pruebas de carga viral < 200 copias por ml durante 2019) mediante la realización de un estudio de cohorte retrospectivo de clientes manejados médicamente por el Programa Ryan White del condado de Miami-Dade (RWP). Se obtuvieron medidas resumidas de las prácticas de atención centradas en el paciente de los proveedores afiliados a RWP usando una encuesta de 1352 clientes. Los modelos de redes bayesianos analizaron la relación compleja entre los factores psicosociales y de atención centrada en el paciente. De 5037 clientes, 4135 (82,1%) tenían una supresión viral duradera. Los ingresos del hogar fueron el factor asociado con la supresión viral duradera más fuerte. Además, la puntuación promedia de la relación con proveedores de atención médica y la puntuación promedia de "el proveedor conoce al paciente como persona" fueron asociados con una supresión viral duradera. La puntuación de la relación con proveedores de atención médica moderó la asociación entre los ingresos bajos del hogar y la falta de supresión viral duradera. Aunque la atención centrada en el paciente apoya el éxito de la atención médica del VIH, también se necesita un apoyo integral para las personas con necesidades psicosociales insatisfechas.

Exploring the use of self-management strategies for antiretroviral therapy adherence among women with HIV in the Miami-Dade County Ryan White Program.

Women with HIV (WWH) face increased difficulties maintaining adherence to antiretroviral therapy (ART) due to a variety of demographic and psychosocial factors. To navigate the complexities of ART regimens, use of strategies to maintain adherence is recommended. Research in this area, however, has largely focused on adherence interventions, and few studies have examined self-reported preferences for adherence strategies. The purpose and objectives of this study were to explore the use of ART self-management strategies among a diverse sample of WWH, examine demographic and psychosocial differences in strategy use, and assess the association between strategies and ART adherence. The current study presents secondary data of 560 WWH enrolled in the Miami-Dade County Ryan White Program. Participants responded to questionnaire items assessing demographic and psychosocial characteristics, use of adherence strategies, and ART adherence during the past month. Principal component analysis identified four categories among the individual strategies and multivariable binomial logistic regression assessed adherence while controlling for individual-level factors. The majority of WWH reported optimal ART adherence, and nearly all used multiple individual strategies. The number of individual strategies used and preferences for strategy types were associated with various demographic and psychosocial characteristics. Adjusting for demographic and psychosocial characteristics, optimal ART adherence during the past month was associated with the use of four or more individual strategies. When conducting regular assessments of adherence, it may be beneficial to also assess use of adherence strategies and to discuss with WWH how using multiple strategies contributes to better adherence.

How patients experience respect in healthcare: findings from a qualitative study among multicultural women living with HIV.

BACKGROUND: Respect is essential to providing high quality healthcare, particularly for groups that are historically marginalized and stigmatized. While ethical principles taught to health professionals focus on patient autonomy as the object of respect for persons, limited studies explore patients' views of respect. The purpose of this study was to explore the perspectives of a multiculturally diverse group of low-income women living with HIV (WLH) regarding their experience of respect from their medical physicians. METHODS: We analyzed 57 semi-structured interviews conducted at HIV case management sites in South Florida as part of a larger qualitative study that explored practices facilitating retention and adherence in care. Women were eligible to participate if they identified as African American (n = 28), Hispanic/Latina (n = 22), or Haitian (n = 7). They were asked to describe instances when they were treated with respect by their medical physicians. Interviews were conducted by a fluent research interviewer in either English, Spanish, or Haitian Creole, depending on participant's language preference. Transcripts were translated, back-translated and reviewed in entirety for any statements or comments about "respect." After independent coding by 3 investigators, we used a consensual thematic analysis approach to determine themes. RESULTS: Results from this study grouped into two overarching classifications: respect manifested in physicians' orientation towards the patient (i.e., interpersonal behaviors in interactions) and respect in medical professionalism (i.e., clinic procedures and practices). Four main themes emerged regarding respect in provider's orientation towards the patient: being treated as a person, treated as an equal, treated without blame or prejudice, and treated with concern/emotional support. Two main themes emerged regarding respect as evidenced in medical professionalism: physician availability and considerations of privacy. CONCLUSIONS: Findings suggest a more robust conception of what 'respect for persons' entails in medical ethics for a diverse group of low-income women living with HIV. Findings have implications for broadening areas of focus of future bioethics education, training, and research to include components of interpersonal relationship development, communication, and clinic procedures. We suggest these areas of training may increase respectful medical care experiences and potentially serve to influence persistent and known social and structural determinants of health through provider interactions and health care delivery.

Effects of Implicit Racial Bias and Standardized Patient Race on Genetic Counseling Students' Patient-Centered Communication.

Clinician racial bias has been associated with less patient-centered communication, but little is known about how it affects trainees' communication. We investigated genetic counseling students' communication during sessions with Black or White standardized patients (SPs) and the extent to which communication was associated with SP race or student scores on the Race Implicit Association Test (IAT). Sixty students conducted a baseline SP session and up to two follow-up sessions. Students were randomly assigned to a different White or Black SP and one of three clinical scenarios for each session. Fifty-six students completed the IAT. Session recordings were coded using the Roter Interaction Analysis System. Linear regression models assessed the effects of IAT score and SP race on a variety of patient-centered communication indicators. Random intercept models assessed the within-student effects of SP race on communication outcomes during the baseline session and in follow-up sessions (n = 138). Students were predominantly White (71%). Forty students (71%) had IAT scores indicating some degree of pro-White implicit preference. Baseline sessions with White relative to Black SPs had higher patient-centeredness scores. Within-participant analyses indicate that students used a higher proportion of back-channels (a facilitative behavior that cues interest and encouragement) and conducted longer sessions with White relative to Black SPs. Students' stronger pro-White IAT scores were associated with using fewer other facilitative statements during sessions with White relative to Black SPs. Different patterns of communication associated with SP race and student IAT scores were found for students than those found in prior studies with experienced clinicians.

Does the Quality of Behavior Change Counseling in Routine HIV Care Vary According to Topic and Demand?

HIV clinicians face increasing time constraints. Our objective was to describe the prevalence and quality of behavior change counseling within routine HIV visits and to explore whether clinicians may provide lower quality counseling when facing increased counseling demands. We audio-recorded and transcribed encounters between 205 patients and 12 clinicians at an urban HIV primary care clinic. We identified and coded episodes of behavior change counseling to determine clinicians' consistency with motivational interviewing (MI) and used multi-level regression to evaluate counseling quality changes with each additional topic. Clinician counseling for at least one behavior was indicated in 92% of visits (mean 2.5/visit). Behavioral topics included antiretroviral medication adherence (80%, n = 163), appointment adherence (54%, n = 110), drug use (46%, n = 95), tobacco use (45%, n = 93), unsafe sex (43%, n = 89), weight management (39%, n = 80), and alcohol use (35%, n = 71). Clinician counseling was most MI-consistent when discussing drug and tobacco use and least consistent for medication and appointment adherence, unsafe sex, and alcohol use. In multilevel analyses, clinician counseling was significantly less MI-consistent (ß = - 0.14, 95% CI - 0.29 to - 0.001) with each additional behavior change counseling need. This suggests that HIV ambulatory care be restructured to allocate increased time for patients with greater need for behavior change.

Sex differences in psychosocial and demographic factors associated with sustained HIV viral suppression in the Miami-Dade County Ryan White Program, 2017.

This exploratory study examined sex differences in psychosocial and demographic factors associated with sustained HIV viral suppression (SVS). The study population included 6,489 Miami-Dade Ryan White Program (RWP) clients receiving services during 2017; administrative data was analyzed. SVS was defined as having all viral load tests during 2017 below 200 copies/ml. Multilevel logistic regression models accounted for clustering by medical case management site. Models were stratified by sex. Overall, a higher proportion of females did not achieve SVS (23.5%) than males (18.1%). For females (n = 1,503), having acquired HIV perinatally and not having a partner oradult household member were associated with not achieving SVS. For males (n = 4,986), lacking access to food, Black or Haitian race/ethnicity, problematic substance use, and unknown physician were associated with not achieving SVS. For both sexes, younger age, lower household income, ever having an AIDS diagnosis, feeling depressed or anxious, and experiencing homelessness were associated with not achieving SVS. Elements of the transition from adolescent to adult HIV care that may differentially impact female clients and factors associated with disclosure should be explored further. Male clients may require additional support for food security. Improving culturally specific care for Haitian and non-Hispanic Black male clients should also be explored.

Digital Scarlet Letters: Sexually Transmitted Infections in the Electronic Medical Record.

ABSTRACT: The harms of implicit bias in clinical settings are acknowledged but poorly understood and difficult to overcome. We discuss how structural components of electronic medical record (EMR) user interfaces may contribute to sex and gender-based discrimination against patients via constant, duplicative presentation of stigmatizing sexually transmitted infection (STI) data irrespective of clinical significance. Via comparison with symbolism and representative quotes in Hawthorne's 1850 novel The Scarlet Letter, we propose a metaphor to examine how EMRs function as a platform for moral judgment, which may display an indelible "scarlet letter" for pregnant patients with STI history. We consider whether current depictions of STIs in EMRs are structurally unjust and may contribute to biased treatment by directing attention to violations of hegemonic sex/gender norms regarding sexual behavior and thus triggering moral judgments of maternal fitness. We conclude with recommendations for how to address these challenges to improve ethical stewardship of sensitive sexual/reproductive health data.

Investigating the impact of the COVID-19 pandemic on breast cancer clinicians' communication about sexual health.

PURPOSE: We assessed breast cancer clinicians' perspectives on how the COVID-19 pandemic and increased use of telehealth affected their clinical communication about sexual heath. METHODS: Breast cancer clinicians participating in a sexual health communication intervention study (N = 29; 76% female; 66% oncologists; 34% advanced practice clinicians) completed an online survey. Data analysis consisted of descriptive statistics and thematic analysis. RESULTS: All clinicians were using telehealth, with most (66%) using it for up to half of their clinic appointments. Although only 14% of clinicians reported having shorter clinic visits, 28% reported having less time to discuss sexual health; 69% reported no change; and 3% said they had more time. Forty-one percent reported sexual health was less of a priority; 55% reported no change; and 3% said it was more of a priority. Thirty-five percent reported telehealth was less conducive to discussing sexual health; 59% reported no change; and 7% reported more conducive. Qualitative analysis revealed key issues underlying the perceived impact of the pandemic on discussions of sexual health including heightened clinician discomfort discussing such issues via telehealth, the less personal nature and privacy issues in telehealth visits, increased concerns about risk of COVID-19 infection and other health concerns (e.g., missing recurrence, mental health) taking priority, and clinician-perceived patient factors (e.g., discomfort, decreased priority) in discussing sexual concerns. CONCLUSION: Pandemic-related changes in breast cancer clinicians' practice could be exacerbating challenges to discussing sexual health. Methods for integrating sexual health into cancer care are needed, regardless of the mode of delivery.

Testimonial Injustice: Linguistic Bias in the Medical Records of Black Patients and Women.

BACKGROUND: Black Americans and women report feeling doubted or dismissed by health professionals. OBJECTIVE: To identify linguistic mechanisms by which physicians communicate disbelief of patients in medical records and then to explore racial and gender differences in the use of such language. DESIGN: Cross-sectional. SETTING/PARTICIPANTS: All notes for patients seen in an academic ambulatory internal medicine practice in 2017. MAIN MEASURES: A content analysis of 600 clinic notes revealed three linguistic features suggesting disbelief: (1) quotes (e.g., had a "reaction" to the medication); (2) specific "judgment words" that suggest doubt (e.g., "claims" or "insists"); and (3) evidentials, a sentence construction in which patients' symptoms or experience is reported as hearsay. We used natural language processing to evaluate the prevalence of these features in the remaining notes and tested differences by race and gender, using mixed-effects regression to account for clustering of notes within patients and providers. KEY RESULTS: Our sample included 9251 notes written by 165 physicians about 3374 unique patients. Most patients were identified as Black (74%) and female (58%). Notes written about Black patients had higher odds of containing at least one quote (OR 1.48, 95% CI 1.20-1.83) and at least one judgment word (OR 1.25, 95% CI 1.02-1.53), and used more evidentials (ß 0.32, 95% CI 0.17-0.47), compared to notes of White patients. Notes about female vs. male patients did not differ in terms of judgment words or evidentials but had a higher odds of containing at least one quote (OR 1.22, 95% CI 1.05-1.44). CONCLUSIONS: Black patients may be subject to systematic bias in physicians' perceptions of their credibility, a form of testimonial injustice. This is another potential mechanism for racial disparities in healthcare quality that should be further investigated and addressed.

Effect of Outpatient Note Templates on Note Quality: NOTE (Notation Optimization through Template Engineering) Randomized Clinical Trial.

BACKGROUND: This is the first randomized controlled trial evaluating the impact of note template design on note quality using a simulated patient encounter and a validated assessment tool. OBJECTIVE: To compare note quality between two different templates using a novel randomized clinical simulation process. DESIGN: A randomized non-blinded controlled trial of a standard note template versus redesigned template. PARTICIPANTS: PGY 1-3 IM residents. INTERVENTIONS: Residents documented the simulated patient encounter using one of two templates. The standard template was modeled after the usual outpatient progress note. The new template placed the assessment and plan section in the beginning, grouped subjective data into the assessment, and deemphasized less useful elements. MAIN MEASURES: Note length; time to note completion; note template evaluation by resident authors; note evaluation by faculty reviewers. KEY RESULTS: 36 residents participated, 19 randomized to standard template, 17 to new. New template generated shorter notes (103 vs 285 lines, p < 0.001) that took the same time to complete (19.8 vs 21.6 min, p = 0.654). Using a 5-point Likert scale, residents considered new notes to have increased visual appeal (4 vs 3, p = 0.05) and less redundancy and clutter (4 vs 3, p = 0.006). Overall template satisfaction was not statistically different. Faculty reviewers rated the standard note more up-to-date (4.3 vs 2.7, p = 0.001), accurate (3.9 vs 2.6, p = 0.003), and useful (4 vs 2.8, p = 0.002), but less organized (3.3 vs 4.5, p < 0.001). Total quality was not statistically different. CONCLUSIONS: Residents rated the new note template more visually appealing, shorter, and less cluttered. Faculty reviewers rated both note types equivalent in the overall quality but rated new notes inferior in terms of accuracy and usefulness though better organized. This study demonstrates a novel method of a simulated clinical encounter to evaluate note templates before the introduction into practice. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT04333238.

Hypoglycemia Communication in Primary Care Visits for Patients with Diabetes.

BACKGROUND: Hypoglycemia is a common and serious adverse effect of diabetes treatment, especially for patients using insulin or insulin secretagogues. Guidelines recommend that these patients be assessed for interval hypoglycemic events at each clinical encounter and be provided anticipatory guidance for hypoglycemia prevention. OBJECTIVE: To determine the frequency and content of hypoglycemia communication in primary care visits. DESIGN: Qualitative study PARTICIPANTS: We examined 83 primary care visits from one urban health practice representing 8 clinicians and 33 patients using insulin or insulin secretagogues. APPROACH: Using a directed content analysis approach, we analyzed audio-recorded primary care visits collected as part of the Achieving Blood Pressure Control Together study, a randomized trial of behavioral interventions for hypertension. The coding framework included communication about interval hypoglycemia, defined as discussion of hypoglycemic events or symptoms; the components of hypoglycemia anticipatory guidance in diabetes guidelines; and hypoglycemia unawareness. Hypoglycemia documentation in visit notes was compared to visit transcripts. KEY RESULTS: Communication about interval hypoglycemia occurred in 24% of visits, and hypoglycemic events were reported in 16%. Despite patients voicing fear of hypoglycemia, clinicians rarely assessed hypoglycemia frequency, severity, or its impact on quality of life. Hypoglycemia anticipatory guidance was provided in 21% of visits which focused on diet and behavior change; clinicians rarely counseled on hypoglycemia treatment or avoidance of driving. Limited discussions of hypoglycemia unawareness occurred in 8% of visits. Documentation in visit notes had low sensitivity but high specificity for ascertaining interval hypoglycemia communication or hypoglycemic events, compared to visit transcripts. CONCLUSIONS: In this high hypoglycemia risk population, communication about interval hypoglycemia and counseling for hypoglycemia prevention occurred in a minority of visits. There is a need to support clinicians to more regularly assess their patients' hypoglycemia burden and enhance counseling practices in order to optimize hypoglycemia prevention in primary care.

Mobile Technology-Based (mLearning) Intervention to Enhance Breast Cancer Clinicians' Communication About Sexual Health: A Pilot Trial.

BACKGROUND: Most breast cancer clinicians lack training to counsel patients about sexual concerns. The purpose of this study was to assess the feasibility, acceptability, and preliminary effects of a mobile learning (mLearning) intervention (improving Sexual Health and Augmenting Relationships through Education [iSHARE]) aimed at enhancing breast cancer clinicians' knowledge of, beliefs about, and comfort with discussing patients' sexual health concerns. METHODS: Clinicians listened to a 2-part educational podcast series offering information on breast cancer-related sexual health concerns and effective communication on the topic, which consisted of interviews with expert guests. Intervention feasibility was assessed through rates of enrollment, retention, and intervention completion, with benchmarks of 40%, 70%, and 60%, respectively. Acceptability was assessed through program evaluations, with 75% of clinicians rating the intervention favorably (eg, relevance, satisfaction) signifying acceptability. Clinicians self-reported their knowledge about breast cancer-related sexual health concerns, beliefs (ie, self-efficacy for discussing sexual health concerns), and comfort with discussing sexual concerns measured at preintervention and postintervention. Qualitative analysis examined clinicians' perceptions of lessons learned from the intervention. RESULTS: A total of 32 breast cancer clinicians enrolled (46% of those invited; 97% of those who responded and screened eligible), 30 (94%) completed both the intervention and study surveys, and 80% rated the intervention favorably, demonstrating feasibility and acceptability. Results showed positive trends for improvement in clinician knowledge, beliefs, and comfort with discussing sexual health concerns. Clinicians reported key lessons learned, including taking a proactive approach to discussing sexual health concerns, normalizing the topic, addressing vaginal health, sending the message that help is available, and assessing sexual health concerns with patients from different backgrounds. CONCLUSIONS: Breast cancer clinicians were amenable to participating in the iSHARE intervention and found it useful. iSHARE showed promise for improving clinician's knowledge and comfort discussing patients' sexual health concerns. A larger trial is required to demonstrate efficacy. Future studies should also examine whether iSHARE can improve patient-clinician communication and address patients' sexual concerns.

Clinician Response to Patient Emotion: Impact on Subsequent Communication and Visit Length.

PURPOSE: It is widely cited-based on limited evidence-that attending to a patient's emotions results in shorter visits because patients are less likely to repeat themselves if they feel understood. We evaluated the association of clinician responses to patient emotions with subsequent communication and visit length. METHODS: We audio-recorded 41 clinicians with 342 unique patients and used the Verona Coding Definitions of Emotional Sequences (VR-CoDES) to time stamp patient emotional expressions and categorize clinician responses. We used random-intercept multilevel-regression models to evaluate the associations of clinician responses with timing of the expressed emotion, patient repetition, and subsequent length of visit. RESULTS: The mean visit length was 30.4 minutes, with 1,028 emotional expressions total. The majority of clinician responses provided space for the patient to elaborate on the emotion (81%) and were nonexplicit (56%). As each minute passed, clinicians had lower odds of providing space (odds ratio [OR] = 0.96; 95% CI, 0.95-0.98) and higher odds of being explicit (OR = 1.02; 95% CI, 1.00-1.03). Emotions were more likely to be repeated when clinicians provided space (OR = 2.33; 95% CI, 1.66-3.27), and less likely to be repeated when clinicians were explicit (OR = 0.61; 95% CI, 0.47-0.80). Visits were shorter (ß = -0.98 minutes; 95% CI, -2.19 to 0.23) when clinicians' responses explicitly focused on patient affect. CONCLUSION: If saving time is a goal, clinicians should consider responses that explicitly address a patient's emotion. Arguments for providing space for patients to discuss emotional issues should focus on other benefits, including patients' well-being.

The Patient Reported Outcomes as a Clinical Tool (PROACT) Pilot Study: What Can be Gained by Sharing Computerized Patient-Reported Mental Health and Substance Use Symptoms with Providers in HIV Care?

Substance use and mental health (SU/MH) disorders are insufficiently recognized in HIV care. We examined whether conveying SU/MH screening results to patients and providers increased SU/MH discussions and action plans. Intervention participants completed a computerized patient-reported questionnaire before their HIV visit; screened positive on ≥ 1 measure: depression, anxiety, PTSD symptoms, at-risk alcohol use, or drug use; and reviewed screening results to decide which to prioritize with their provider. Screening results and clinical recommendations were conveyed to providers via medical record. A historic control included patients with positive screens but no conveyance to patient or provider. The patient-provider encounter was audio-recorded, transcribed, and coded. For the overall sample (n = 70; 38 control, 32 intervention), mean age (SD) was 51.8 (10.3), 61.4% were male, and 82.9% were Black. Overall, 93.8% raised SU/MH in the intervention compared to 50.0% in the control (p < 0.001). Action plans were made for 40.0% of intervention and 10.5% of control encounters (p = 0.049). Conveying screening results with clinical recommendations increased SU/MH action plans, warranting further research on this intervention to address SU/MH needs.

Impact of Physician Race on Patient Decision-Making and Ratings of Physicians: a Randomized Experiment Using Video Vignettes.

BACKGROUND: Studies suggest that black patients have better interactions, on average, with physicians of their own race. Whether this reflects greater "cultural competence" in race-concordant relationships, or other effects of race unrelated to physician behavior, is unclear. It is also unclear if physician race influences patient decision-making. OBJECTIVE: To determine whether physician race affects patients' ratings of physicians and decision-making, independent of physician behavior. DESIGN: Randomized study using standardized video vignettes. PARTICIPANTS: Primary care patients with coronary risk factors or disease. INTERVENTIONS: Each participant viewed one of 16 vignettes depicting a physician reviewing cardiac catheterization results and recommending coronary artery bypass graft (CABG) surgery. Vignettes varied only in terms of physicians' race, gender, age, and communication style (high vs. low patient-centeredness). MAIN MEASURES: Participants rated the video physician's communication, interpersonal style, competence, trustworthiness, likability, and overall performance (0-4 Likert scales). They also rated the necessity of CABG (0-5 scale) and whether they would undergo CABG or obtain a second opinion if they were the video patient (0-3 scales). KEY RESULTS: Participants included 107 black and 131 white patients (72% participation rate). Black participants viewing a black (vs. white) video physician gave higher ratings on all physician attributes (e.g., overall rating 3.22 vs. 2.34, p < 0.001) and were more likely to perceive CABG as necessary (4.05 vs. 3.72, p = 0.03) and say they would undergo CABG if they were the video patient (2.43 vs. 2.09, p = 0.004). Patient-centered communication style reduced, but did not eliminate, the impact of race concordance. Physician race was not associated with any outcomes among white patients. CONCLUSIONS: Black patients viewed the doctor in a scripted vignette more positively, and were more receptive to the same recommendation, communicated in the same way, with a black vs. white physician. Patient-centered communication reduced but did not eliminate the effect of physician race.

Understanding Sexual Help-Seeking for Women With Breast Cancer: What Distinguishes Women Who Seek Help From Those Who Do Not?

BACKGROUND: Sexual problems are extremely common for women after breast cancer (BC). AIM: To determine, in a sample of BC outpatients, how commonly women sought help for sexual concerns, from a health care provider (HCP), from other individuals, or from alternate sources; and to examine whether help-seeking was associated with women's sexual function/activity, self-efficacy for clinical communication about sexual health, or sociodemographic/medical characteristics. METHODS: BC patients participating in a sexual/menopausal health communication intervention trial completed web-based baseline self-report surveys. One-way analysis of variances compared effects of the level of sexual help-seeking (none; 1 outlet; 2-3 outlets) on sexual function domains. Chi-square or t-tests compared women seeking help with those not seeking help on other study variables. MAIN OUTCOME MEASURES: Patient-reported outcome instruments assessed sexual help-seeking (past month), sexual function and activity (PROMIS Sexual Function and Satisfaction Brief Profile Version 2.0), and self-efficacy (confidence) for communicating with their BC clinician about sexual health. RESULTS: 144 women (mean age = 56.0 years; 62% partnered; 67% white; 27% black/African American; 4% Hispanic/Latina; 15% stage IV) participated in this study. 49% of women sought help for sexual concerns, most often from intimate partners, family and/or friends (42%), followed by HCPs (24%), or online/print materials (19%); very few women (n = 4; 3%) sought help only from a HCP. Women seeking help were younger and more likely to be partnered and sexually active than those not seeking help. Sexual function was impaired for all domains but was most impaired for sexual interest. Among sexually active women, those seeking help from 2 to 3 sources reported worse sexual function in certain domains (sexual interest, lubrication, vaginal discomfort, vulvar discomfort-labial, satisfaction). Women seeking help from outlets other than HCPs had significantly lower self-efficacy than those who did not. CLINICAL IMPLICATIONS: BC patients with access to a partner and who are sexually active but find sex unsatisfying, uncomfortable, or lack interest may be in particular need of sexual help. Further, women may turn to outlets other than HCPs for sexual help partly because they lack the confidence to do so with a HCP. Sexual health information should be made available to women's partners, family, and friends, so they may effectively discuss such issues if needed. STRENGTHS & LIMITATIONS: Strengths of the study included examination of a range of sexual function domains and a theoretical construct in relation to BC patients' sexual help-seeking and a medically diverse sample. Limitations include a cross-sectional design. CONCLUSION: Women treated for BC should receive accurate and timely sexual health information. Reese JB, Sorice KA, Pollard W, et al. Understanding Sexual Help-Seeking for Women With Breast Cancer: What Distinguishes Women Who Seek Help From Those Who Do Not? J Sex Med 2020;17:1729-1739.

Patients' perceived barriers to discussing sexual health with breast cancer healthcare providers.

OBJECTIVES: We characterized barriers reported by women with breast cancer (BC) regarding clinical discussions of sexual health, clustered women by their endorsement of these barriers, and compared these groups. METHODS: BC outpatients (N = 144; M age = 56, 67% White) in a sexual health communication intervention study provided baseline data. Exploratory factor analysis characterized sexual health communication barriers on a standardized measure. Hierarchical cluster analysis detected patient groups with similar response patterns on these factors. ANOVAs, Chi-Square and Fisher's Exact tests compared groups on socio-demographic/medical factors, sexual health communication self-efficacy and outcome expectancies, general clinical self-efficacy, sexual concerns, emotional distress, and discussion about sexual health with an oncology provider. RESULTS: Two factors emerged: patients' own beliefs about or perceived inability to discuss sexual health (self-centered barriers), and patients' perceptions of providers' reactions to discussing sexual health (provider-centered barriers); self-centered barriers were endorsed more than provider-centered (P < .001). Three clusters emerged: women who endorsed (a) high self-centered and high provider-centered (n = 19; 13%), (b) high self-centered and low provider-centered (n = 95; 66%), and (c) low self-centered and low provider-centered (n = 30; 21%). Women endorsing more barriers reported lower sexual communication self-efficacy, outcome expectancies, and general clinical self-efficacy (P's ≤ .001); no differences in sexual concerns, emotional distress, or discussing sexual health were found. CONCLUSIONS: Women more strongly endorsed self-centered barriers than provider-centered. When grouped according to these barriers, women differed in their confidence and expectations for sexual health communication, regardless of degree of sexual or emotional distress. Interventions are needed to improve both patients' and providers' skills for discussing sexual health.

Genetic counselor implicit bias and its effects on cognitive and affective exchanges in racially discordant simulations.

Previous studies have linked clinicians' implicit racial bias with less patient-centered communication between healthcare providers and patients in a variety of healthcare contexts. The current study extends this research by exploring the influence of implicit racial bias in genetic counselors' (GCs') facilitation of simulated clients' cognitive and emotional processing during genetic counseling sessions. We conducted a secondary analysis of a nationally representative sample of genetic counseling sessions of White and ethnic and/or racial minority (Black and Latinx) simulated clients with a subset of 60 GCs who had completed a Race Implicit Association Test (IAT). Linguistic Inquiry Word Count (LIWC) was applied to session transcripts to identify word use by the simulated client consistent with emotional and cognitive processing. The Roter Interaction Analysis System (RIAS) was used to link GC statements consistent with facilitation of emotional and cognitive processing, as used in previous studies. Multiple linear regression analyses were performed to relate LIWC and RIAS variables to GC IAT scores, client race/ethnicity, and statistical interaction between GC IAT scores and client race/ethnicity. GCs used more cognitive facilitation strategies with ethnic and/or racial minority than with White clients (p = .04). There were no statistically significant associations between GCs' pro-White implicit bias and GCs' facilitation of cognitive and emotional processing or clients' use of positive, negative, or cognitive process words. While implicit bias may affect some communication processes, our analysis did not show a relationship between GC IAT score and how GCs help clients process emotional or cognitive information conveyed during a session. It is also possible that the LIWC measure of cognitive and emotional processing is not a sensitive enough measure to capture an implicit bias effect if indeed one is present.

Student Perceptions of M.D.-Ph.D. Programs: A Qualitative Identification of Barriers Facing Prospective M.D.-Ph.D. Applicants.

Phenomenon: Despite a high degree of interest in research among matriculating M.D. students, very few apply to combined M.D.-Ph.D. training programs. Even fewer of those applicants are female, leading to a gender disparity among M.D.-Ph.D. trainees. We used a qualitative approach to understand why students choose not to apply or matriculate to M.D.-Ph.D. programs. Approach: We recruited recently matriculated medical students at a private research university with a self-reported interest in academic medicine and biomedical research to participate in focus groups, in which students discussed their career and life goals, general knowledge and sources of information for M.D.-Ph.D. programs, perceived benefits and downsides, and barriers to applying to such programs. Findings: Twenty-two students participated in focus groups. Participants desired careers combining clinical work, research, and teaching. Students had knowledge of the structure and goals of M.D.-Ph.D. training and received information about dual-degree programs from research mentors, the Internet, and peers. Tuition remission and increased grant access were cited as benefits of M.D.-Ph.D. programs, whereas duration, perceived excessive research training, and early commitment were downsides. Perceived competitiveness, misconceptions about training, a lack of M.D.-Ph.D. program-specific advising, discouragement from applying, and duration of training all served as barriers preventing students from pursuing dual-degree training. Insights: Through this qualitative study, we identified perceptions and misconceptions that recent medical school applicants have about M.D.-Ph.D. programs. These findings suggest targetable barriers to increase applications from interested students, such as improving awareness of programs, increased accessibility of advising and resources, and addressing concerns over training length, with the goal of improving training access for aspiring physician-scientists.