Integrating Discussions on Racism and Health Equity into Clinical Reasoning Conference.

OBJECTIVE: Intentionally discussing racism and health equity in clinical reasoning conference may provide an opportunity to reinforce antiracist praxis. We aimed to understand 1) whether these discussions provide a meaningful opportunity to practice applying an antiracist lens in patient care, 2) the feasibility of implementing these discussions in a clinical reasoning format, and 3) the acceptability to Black, Indigenous, and People of Color (BIPOC) and white residents. METHODS: In 2021, 4 clinical reasoning conference pilot sessions were implemented in a pediatrics residency program. Trained faculty facilitated discussions on mitigating inequity in clinical cases. Residents who attended at least 1 session were invited to participate in focus groups, which were analyzed using grounded theory. RESULTS: Thirty residents attended each pilot session out of the 30 to 35 who had the opportunity to attend. The focus groups included 6 BIPOC and 6 white residents. The discussions offered a meaningful opportunity to practice recognizing and naming racism. Having faculty facilitators made the discussions more feasible. Both groups experienced benefits and wanted the discussions to continue, but BIPOC residents want more engagement from their white peers. CONCLUSIONS: Discussing racism and health equity in clinical reasoning conference was a meaningful, feasible, and acceptable opportunity for antiracist praxis.

Upholding Our PROMISE: Underrepresented in Medicine Pediatric Residents' Perspectives on Interventions to Promote Belonging.

PURPOSE: Underrepresented in medicine (UIM) residents experience challenges during training that threaten their sense of belonging in medicine; therefore, residency programs should intentionally implement interventions to promote belonging. This study explored UIM pediatric residents' perspectives on current residency program measures designed to achieve this goal. METHOD: The authors conducted a secondary qualitative analysis as part of a national cross-sectional study, PROmoting Med-ed Insight into Supportive Environments (PROMISE), which explored pediatric residents' experiences and perspectives during training in relation to their self-identities. A 23-item web-based survey was distributed through the Association of Pediatric Program Directors Longitudinal Educational Research Assessment Network from October 2020 to January 2021. Participants provided free-text responses to the question "What are current measures that promote a sense of belonging for the UIM community in your training program?" The authors used conventional content analysis to code and identify themes in responses from UIM participants. RESULTS: Of the 1,748 residents invited to participate, 931 (53%) residents from 29 programs completed the survey, with 167 (18%) identifying as UIM. Of the 167 UIM residents, 74 (44%) residents from 22 programs responded to the free-text question. The authors coded more than 140 unique free-text responses and identified 7 major themes: (1) critical mass of UIM residents; (2) focused recruitment of UIM residents; (3) social support, including opportunities to build community among UIM residents; (4) mentorship; (5) caring and responsive leadership; (6) education on health disparities, diversity, equity, inclusion, and antiracism; and (7) opportunities to serve, including giving back to the local community and near-peer mentorship of UIM premedical and medical students. CONCLUSIONS: This is the first national study to describe UIM pediatric residents' perspectives on interventions that promote a sense of belonging. Programs should consider implementing these interventions to foster inclusion and belonging among UIM trainees.

The Power of Place: Travel to Explore Structural Racism and Health Disparities.

PROBLEM: Dismantling structural racism is essential to achieving health equity, but there is little guidance for medical educators who wish to teach learners to recognize and confront structural racism. APPROACH: Critical consciousness provides a framework to identify and dismantle structural racism. Using a critical consciousness approach, the authors developed a novel 5-day travel experience to the American South for medical residents and faculty to explore the history and legacy of structural racism and the Civil Rights Movement. The purpose of the travel was to examine the connection between structural racism, especially anti-Black racism, and health disparities to better address health inequities within the participants' own home environment. Throughout the trip, faculty leaders applied principles of cultural humility and techniques from critical pedagogy, including recognizing the value of everyone in the room, creating cognitive disequilibrium, and promoting authentic dialogue. OUTCOMES: End-of-week surveys revealed that the trip was well received. Organizers learned important lessons related to faculty and resident dynamics, race-based affinity group meetings, and the respectful use of stories as a tool for learning. Post-trip surveys at 1, 6, and 12 months revealed 3 major themes: participants experienced (1) transformed understanding of systemic racism, (2) increased motivation and bravery to act when witnessing interpersonal and structural racism, and (3) increased practice of cultural humility. NEXT STEPS: Cultural humility and critical pedagogy can be used with travel to support learners in recognizing and confronting structural racism. The application of such techniques should be explored in local learning environments to foster commitment and action toward dismantling structural racism. In teaching structural racism, medical educators must be willing to consider new ways of teaching and learning.

Improving Diversity in Pediatric Residency Selection: Using an Equity Framework to Implement Holistic Review.

BACKGROUND: Many programs struggle to recruit, select, and match a diverse class of residents, and the most effective strategies for holistic review of applications to enhance diversity are not clear. OBJECTIVE: We determined if holistic pediatric residency application review guided by frameworks that assess for bias along structural, interpersonal, and individual levels would increase the number of matched residents from racial and ethnic groups that are underrepresented in medicine (UiM). METHODS: Between 2017 and 2020, University of California San Francisco Pediatrics Department identified structural, interpersonal, and individual biases in existing selection processes and developed mitigation strategies in each area. Interventions included creating a shared mental model of desirable qualities in residents, employing a new scoring rubric, intentional inclusion of UiM faculty and trainees in the selection process, and requiring anti-bias training for everyone involved with recruitment and selection. RESULTS: Since implementing these changes, the percentage of entering interns who self-identify as UIM increased from 11% in 2015 to 45% (OR 6.8, P = .008) in 2019 and to 35% (OR 4.6, P = .035) in 2020. CONCLUSIONS: Using an equity framework to guide implementation of a pediatric residency program's holistic review of applications increased the numbers of matched UiM residents over a 3-year period.

Health Disparities in Tobacco Use and Exposure: A Structural Competency Approach.

Fourteen percent of US adults use tobacco products. Because many of those who use tobacco are parents and/or caregivers, children are disproportionately exposed to tobacco smoke. People who use tobacco products often become addicted to nicotine, resulting in tobacco dependence, a chronic, relapsing disease. Tobacco use and exposure are more likely to occur in vulnerable and marginalized groups, including those living in poverty. Although some view tobacco use as a personal choice, evidence suggests that structural forces play an important role in tobacco uptake, subsequent nicotine addiction, and perpetuation of use. Viewing tobacco use and tobacco dependence through a structural competency lens promotes recognition of the larger systemic forces perpetuating tobacco use, including deliberate targeting of groups by the tobacco industry, lack of enforcement of age-for-sale laws, inferior access to health insurance and health care, poor access to cessation resources, and economic stress. Each of these forces perpetuates tobacco initiation and use; in turn, tobacco use perpetuates the user's adverse health and economic conditions. Pediatricians are urged to view family tobacco use as a social determinant of health. In addition to screening adolescents for tobacco use and providing resources and treatment of tobacco dependence, pediatricians are encouraged to systematically screen children for secondhand smoke exposure and support family members who smoke with tobacco cessation. Additionally, pediatricians can address the structural issues perpetuating tobacco use by becoming involved in policy and advocacy initiatives.

Tobacco Use as a Health Disparity: What Can Pediatric Clinicians Do?

Tobacco use is a global health crisis, and has a tremendous and negative impact on health and wellbeing. Tobacco use disproportionately affects members of vulnerable populations, and by acting on multiple socioecological levels, serves to perpetuate and reinforce cycles of poverty. Members of the pediatric medical community can play a key role in interrupting cycles of tobacco use. Providers can serve as powerful allies to vulnerable communities by treating tobacco use in caregivers, counseling youth against using tobacco products, protecting children from the impact of secondhand smoke exposure, and advocating for economic, social, and health policies to disrupt intergenerational smoking.