Reflexivity and positionality applied to medical practice: a study on implicit gender bias with medical students in a Swiss university.

BACKGROUND: An array of evidence shows how the presence of implicit bias in clinical encounters can negatively impact provider-patient communication, quality of care and ultimately contribute to health inequities. Reflexive practice has been explored as an approach to identify and address implicit bias in healthcare providers, including medical students. At the Lausanne School of Medicine, a clinically integrated module was introduced in 2019 to raise students' awareness of gender bias in medical practice using a reflexivity and positionality approach. The purpose of this study is to describe the gender bias that were identified by medical students, analysing their types, places and modes of emergence during a clinical encounter. It further explores how positionality supported students' reflection on the way in which social position modulates their relationship to patients. METHODS: As part of the teaching activity, medical students individually reflected on gender bias in a specific clinical encounter by answering questions in their electronic portfolio. The questionnaire included a section on positionality. We qualitatively analysed the students' assignments (n=76), applying a thematic analysis framework. RESULTS: Medical students identified and described gender biases occurring at different moments of the clinical encounter (anamnesis (i.e. patient history), physical exam, differential diagnosis, final management). They causally associated these biases with wider social phenomena such as the gendered division of labour or stereotypes around sexuality and gender. Analysing students' reflections on how their position influenced their relationship with patients, we found that the suggested exercise revealed a major contradiction in the process of medical enculturation: the injunction to be neutral and objective erases the social and cultural context of patients and impedes an understanding of gender bias. CONCLUSION: Gender biases are present in the different steps of a clinical consultation and are rooted in broader gendered social representations. We further conclude that the tension between a quest for objectivity and the reality of social encounters should be made explicit to students, because it is constitutive of medical practice.

[Gender bias in clinical management : what can we do ?] / Biais de genre dans la prise en charge médicale : que faire ?

Health data show that there are differences in clinical management based on gender. One hypothesis is that these differences in management are not intentional discrimination but are the result of implicit and unconscious biases on the part of healthcare providers. These biases influence the clinical reasoning and practice of providers. This article, using clinical examples, illustrates how reflective practice is integrated into medical teaching in Lausanne to enable students to identify their biases, control them and ensure fair and relevant care. Students are also prompted to reflect on their social positionality, as thematising the power dynamics around knowledge and social interactions helps to better understand and prepare for medical practice.

Les données en santé font état de différences de traitement médical en fonction du genre. L'une des hypothèses est que ces différences de traitement ne sont pas des discriminations intentionnelles, mais relèvent de biais implicites et inconscients des soignant-e-s. Ces biais ont une influence sur les raisonnements et la pratique clinique des soignant-e-s. Cet article, à l'aide d'exemples cliniques, illustre comment la pratique réflexive est intégrée à l'enseignement en médecine à Lausanne afin de permettre aux étudiant-e-s d'identifier leurs biais, de les contrôler et d'assurer des soins équitables et pertinents. Il est également proposé aux étudiant-e-s de réfléchir à leur positionnement social, car thématiser les dynamiques de pouvoir autour des savoirs et des interactions sociales permet de mieux comprendre et préparer la pratique médicale.

'The body is difficult': reproductive navigation through sociality and corporeality in rural Burundi.

The route from family planning intentions to practices is not linear, it is contingent on different social factors including the preferences of individuals and couples, their gendered positions and bargaining power, the wider political, economic and social context, and also physical and bodily circumstances. We used qualitative data collected in rural Burundi between 2013 and 2016 to explore how these diverse factors influence reproductive navigation in a context framed by uncertainty and changing social norms. We describe representations of bodily (pre)dispositions for fertility and reproduction, such as the 'natural' capacity for birth spacing or the bodily capacity to use 'natural' (having a regular cycle) and 'modern' methods (not having negative side effects) that contribute collectively to an understanding of 'the body is difficult'. We found that despite these bodily constraints, women enact embodied agency to ensure livelihoods and social status, thus framing their reproductive intentions and practices. In the context of Burundi where corporeality is key to gendered social belonging, family planning programmes fail to respond to the needs and concerns of women and their embodied reproductive experiences.

Women Are Underrepresented Among Authors of Retracted Publications: Retrospective Study of 134 Medical Journals.

We examined the gender distribution of authors of retracted articles in 134 medical journals across 10 disciplines, compared it with the gender distribution of authors of all published articles, and found that women were underrepresented among authors of retracted articles, and, in particular, of articles retracted for misconduct.

Use of standardized brief geriatric evaluation compared with routine care in general practice for preventing functional decline: a pragmatic cluster-randomized trial.

BACKGROUND: Although assessment of geriatric syndromes is increasingly encouraged in older adults, little evidence exists to support its systematic use by general practitioners (GPs). The aim of this study was to determine whether a systematic geriatric evaluation performed by GPs can prevent functional decline. METHODS: We conducted a controlled, open-label, pragmatic cluster-randomized trial in 42 general practices in Switzerland. Participating GPs were expected to enrol an average of 10 community-dwelling adults (aged ≥ 75 yr) who understood French, and had visited their GP at least twice in the previous year. The intervention consisted of yearly assessment by the GP of 8 geriatric syndromes with an associated tailored management plan according to assessment results, compared with routine care. Our primary outcomes were the proportion of patients who lost at least 1 instrumental activity of daily living (ADL) and the proportion who lost at least 1 basic ADL, over 2 years. Our secondary outcomes were quality-of-life scores, measured using the older adult module of the World Health Organization Quality of Life Instrument, and health care use. RESULTS: Forty-two GPs recruited 429 participants (63% women) with a mean age of 82.5 years (standard deviation 4.8 yr) at time of recruitment. Of these, we randomly assigned 217 participants to the intervention and 212 to the control arm. The proportion of patients who lost at least 1 instrumental ADL in the intervention and control arms during the course of the study was 43.6% and 47.6%, respectively (risk difference -4.0%, 95% confidence interval [CI] -14.9% to 6.7%, p = 0.5). The proportion of patients who lost at least 1 basic ADL was 12.4% in the intervention arm and 16.9% in the control arm (risk difference -5.1%, 95% CI -14.3% to 4.1%, p = 0.3). INTERPRETATION: A yearly geriatric evaluation with an associated management plan, conducted systematically in GP practices, does not significantly lessen functional decline among community-dwelling, older adult patients, compared with routine care. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02618291.

[Gender in medicine: what contribution to medical practice? Eight selected narratives]. / Le genre en médecine : quels apports pour la pratique ? Huit témoignages choisis.

In this article, we report abstracts of eight interviews, showing how clinicians use their interest in gender in their everyday practice. Clinicians report that being acquainted with a person interested by the question of gender raises their own awareness about the subject. In practice, they notice biased acquisition of knowledge due to non-inclusion of gender in research on one hand, and influence of gender stereotypes on clinical care on the other hand. Gender also influenced carriers. Some interviewed clinicians expressed they wished for more training, to reduce inequalities attributable to gender.

Dans cet article, nous rapportons de brefs extraits de 8 entrevues avec des clinicien·ne·s sensibilisé·e·s au genre, dans le but d'illustrer comment un intérêt pour ce domaine peut influencer la pratique quotidienne. Les personnes interrogées expliquent que le fait d'avoir un·e proche intéressé·e au genre les a rendues attentives à ce sujet. Dans leur pratique, elles disent avoir conscience de biais liés, d'une part, à l'acquisition des connaissances médicales ne tenant pas compte du genre et, d'autre part, à des stéréotypes de genre menant à une pratique médicale inégalitaire. Le genre a aussi un effet sur leurs carrières. Certaines personnes interrogées souhaiteraient bénéficier de plus de formation afin de diminuer les inégalités dues au genre.

Gender awareness among medical students in a Swiss University.

BACKGROUND: Gender is an important social determinant, that influences healthcare. The lack of awareness on how gender influences health might lead to gender bias and can contribute to substandard patient care. Our objectives were to assess gender sensitivity and the presence of gender stereotypes among swiss medical students. METHODS: A validated scale (N-GAMS - Nijmegen Gender Awareness in Medicine Scale), with 3 subscores assessing gender sensitivity (GS) and gender stereotypes toward patients (GRIP) and doctors (GRID) (ranging from 1 to 5), was translated into French and was distributed to all medical students registered at the University of Lausanne, Switzerland in April-May 2017. Reliability of the three subscales was assessed calculating the alpha Cronbach coefficient. Mean subscales were calculated for male and female students and compared using two sample t-tests. A linear model was built with each subscale as a dependent variable and students' sex and age as covariables. RESULTS: In total, 396 students answered the N-GAMS questionnaire, their mean age was 22 years old, 62.6% of them were women. GS and GRID sub-scores were not significantly different between female and male students (GS 3.62 for women, 3.70 for men, p = 0.27, GRID 2.10 for women, 2.13 for men, p = 0.76). A statistically significant difference was found in the GRIP subscale, with a mean score of 1.83 for women and 2.07 for men (p < 0.001), which suggests a more gender stereotyped opinion toward patients among male students. A trend was observed with age, gender sensibility increased (p < 0.001) and stereotypes decreased (GRIP p = 0.04, GRID p = 0.02) with students getting older. CONCLUSION: Medical students' gender sensitivity seems to improve throughout the medical curriculum, and women students have less stereotypes towards patients than men do. The implementation of a gender-sensitive teaching in the medical curriculum could improve students' knowledge, limit gender bias and improve patients' care.

[Reflexivity during medical internships†: how to think about gender in clinical practice]. / Pratique réflexive dans les cours-blocs de médecine ambulatoire ou comment penser le genre en clinique.

Gender bias in medicine negatively interfere with the medical care of both men and women, which can lead to risks for patients as well as health inequalities. Unisanté has launched a pilot project to integrate reflexivity by students at the Medical School of the University of Lausanne on the influence of gender in clinical practice, using an electronic portfolio. The clinical vignettes presented and discussed in this article illustrate this reflective work and the main biases and stereotypes encountered: pain management, assessment of the psychosocial context, management of domestic violence, screening for chlamydia infection and discussion of a contraceptive method.

Les biais de genre en médecine interfèrent négativement avec la prise en charge médicale tant des hommes que des femmes, ce qui peut entraîner des risques pour les patient·e·s et des inégalités de santé. Unisantéaa lancé un projet pilote visant à intégrer l'approche réflexive par les étudiant·e·s de l'École de médecine de l'Université de Lausanne (UNIL) sur l'influence du genre dans la pratique clinique, en utilisant un portfolio électronique. Les vignettes cliniques présentées et discutées dans cet article illustrent ce travail réflexif et les principaux biais et stéréotypes rencontrés : la prise en charge de la douleur, l'évaluation du contexte psychosocial, la prise en charge des violences au sein du couple, le dépistage d'une infection à Chlamydia ainsi que la discussion d'une méthode de contraception.

[Groin hernia in female patients: sex-specific management]. / Hernie inguino-fémorale chez les femmes†: spécificités de prise en charge.

Groin hernia in women is an entity whose clinical manifestations can be quite subtle, and which therefore risks to go unnoticed. Imaging studies by ultrasound or dynamic CT/MRI is strongly recommended in case of a clinical doubt. Optimal treatment consists of laparoscopic surgery, even in oligosymptomatic patients, because the risk of incarceration, and subsequent morbidity and mortality is high especially in cases of femoral hernia, which are frequent and often overlooked in women. During pregnancy, the risk of developing a groin hernia is very low (around 0,1%) and a wait-and-see attitude is to be preferred as much as possible, except in the case of an acute complication (incarceration).

Chez les femmes, la hernie du pli de l'aine est une entité dont les manifestations cliniques peuvent être subtiles, majorant son risque de passer inaperçue. Un bilan d'imagerie, par échographie, voire scanner ou imagerie par résonance magnétique dynamique, est fortement conseillé en cas de doute clinique. Le traitement optimal consiste en une chirurgie par abord laparoscopique, même chez les patientes oligosymptomatiques, car le risque d'incarcération et de morbimortalité est élevé, surtout en cas de hernie fémorale, fréquente et souvent méconnue chez les femmes. Durant la grossesse, le risque de développer une hernie de l'aine est très faible (de l'ordre de 0,1 %) et une attitude attentiste est à privilégier au maximum, sauf en cas de complication aiguë (incarcération).

[Multimorbidity is not a diagnosis]. / La multimorbidité n'est pas une maladie.

We have been studying multimorbidity in epidemiology and clinical practice since the 1970s. Growing experience shows that the concept of multimorbidity is helpful for epidemiologists to describe population-level changes, but of little use to patients and clinicians who 'diagnose' multimorbidity. Several large, rigorous clinical trials show that organizational changes in primary care can improve the care of these complex patients, but do not improve directly health-related quality of life. This article describes the history of multimorbidity and results of recent randomized trials to prompt a discussion of new approaches to improve the experience of people living with multiple chronic diseases.

Depuis plusieurs décennies, la multimorbidité fait l'objet d'études, non seulement en épidémiologie, mais également en médecine générale. Il en ressort que la multimorbidité est essentiellement une entité épidémiologique et les récentes études publiées dans ce domaine tendent à montrer qu'il est difficile d'en faire un concept ayant une réelle consistance clinique. En revanche, la littérature nous apprend également qu'il est essentiel de modifier l'organisation des structures de soins afin d'améliorer la prise en charge de ces patient·e·s particulièrement complexes. Cet article se veut une réflexion autour du concept de multimorbidité dans une perspective historique, ainsi que les besoins de transformation permettant la prise en charge de ces patient·e·s.

[Social determinants of health - how gendergot lost on the way]. / Déterminants sociaux de la santéen Suisse ­ comment le genres'est perdu en chemin.

Since four decades epidemiological research has emphasised the necessity to consider social determinants and the social distribution of illnesses in the Swiss population, particularly by gender. Gender influences social position, living conditions as well as health behaviours over the life-course which all together influence health outcomes. Despite this evidence, national health policies and strategies tend to consider gender as a background factor, if not to omit its influence on health. The Health2020 policy and the recent specific national strategies are particularly illustrative. To exclude or reduce gender as a mere biological factor however hampers the implementation of specific interventions aiming at reducing health inequalities in the name of the social justice principle.

Depuis quatre décennies, la recherche épidémiologique a mis en évidence la nécessité de considérer les déterminants sociaux et la distribution sociale des maladies dans la population suisse, en particulier en fonction du genre. Le genre influence la situation sociale, les conditions et les parcours de vie et les comportements en matière de santé qui influencent ensemble la santé. Malgré ces acquis, les politiques et stratégies nationales de santé tendent à considérer le genre comme un facteur de second plan, voire à omettre totalement son influence sur la santé. La politique Santé2020 et les stratégies nationales spécifiques récentes en témoignent tout particulièrement. Or, exclure ou réduire le genre à un facteur biologique entrave la mise en place d'interventions spécifiques visant la réduction des inégalités de santé au nom du principe de justice sociale.

[Medicine and gender : which challenges for clinical practice ?] / Médecine et genre : quels enjeux pour la pratique ?

Biological sex and social gender jointly influence health. Failure to take into account differences in health between women and men is an issue. What is more, undue differences based on stereotypes can also lead to biased care. This article illustrates the influence of sex and gender on health through clinical situations affecting various dimensions of medical care (diagnosis, investigations, treatments, prognosis). It also gives tools and introduces a project aimed at integrating the gender dimension into the pregraduate education of medical students at the University of Lausanne. The aim is to ensure equitable quality care between women and men, taking into account gender specificities based on unbiased scientific evidence.

Le sexe biologique et le genre social influencent conjointement la santé. La non-prise en compte des différences en santé entre les hommes et les femmes est problématique. En outre, des différences non justifiées sur la base de préconceptions stéréotypées peuvent également conduire à une prise en charge biaisée. Cet article illustre l'influence du sexe et du genre en santé au travers de quelques situations cliniques touchant différents aspects de la prise en charge médicale (diagnostic, investigations, traitements, pronostic). Il donne aussi des outils et présente un projet visant à intégrer la dimension du genre dans le cursus prégradué des étudiant-e-s de médecine de l'Université de Lausanne. L'objectif est d'assurer une prise en charge équitable et de qualité des femmes et des hommes tenant compte des spécificités de genre et basée sur des preuves scientifiques non biaisées.

[« It's normal to get old and weak ¼ : should functional decline be addressed with elderly patients in family medicine ?] / « C'est normal qu'on mollisseou qu'on vieillisse ¼ : faut-il aborderle déclin fonctionnel avec les personnes âgées en médecine de famille ?

Among the health strategies to respond to the aging of the population, initiatives for the screening and management of age-related health issues are implemented, including in family medicine. Preliminary results of a qualitative study suggest that elderly people are ambivalent about anticipating age-related issues, tend to trivialize them and to be reluctant to discuss them spontaneously with their doctors. However, they find relevant that their family doctor brings up the topic with specific questions, because that allows initiating a discussion about some of these sensitive issue. It appears that the awareness of the existing management of geriatric syndromes and functional decline possibilities is rather low. A screening initiative is therefore an opportunity to address these different issues and to inform patients about existing solutions.

Pour répondre au vieillissement de la population, des initiatives de dépistage et de prise en charge des problèmes de santé liés à l'âge sont mises en place, notamment en médecine de famille. Les résultats préliminaires d'une étude qualitative suggèrent que les personnes âgées sont ambivalentes face à la notion d'anticipation des problèmes, tendent à les banaliser et à être réticentes à en parler spontanément à leur médecin. Cependant, elles trouvent pertinent que ce dernier aborde le sujet avec des questions spécifiques, ceci permettant d'initier une discussion sur des problématiques sensibles. Les possibilités de prise en charge des syndromes gériatriques et du déclin fonctionnel semblent peu connues des patient-e-s. Le dépistage permet donc d'aborder ces problématiques et d'informer les patient-e-s au sujet de solutions existantes.

Gender/Sex Disparities in the COVID-19 Cascade From Testing to Mortality: An Intersectional Analysis of Swiss Surveillance Data.

Objectives: This study investigates gender and sex disparities in COVID-19 epidemiology in the Canton of Vaud, Switzerland, focusing on the interplay with socioeconomic position (SEP) and age. Methods: We analyzed COVID-19 surveillance data from March 2020 to June 2021, using an intersectional approach. Negative binomial regression models assessed disparities between women and men, across SEP quintiles and age groups, in testing, positivity, hospitalizations, ICU admissions, and mortality (Incidence Rate Ratios [IRR], with 95% Confidence Intervals [CI]). Results: Women had higher testing and positivity rates than men, while men experienced more hospitalizations, ICU admissions, and deaths. The higher positivity in women under 50 was mitigated when accounting for their higher testing rates. Within SEP quintiles, gender/sex differences in testing and positivity were not significant. In the lowest quintile, women's mortality risk was 68% lower (Q1: IRR 0.32, CI 0.20-0.52), with decreasing disparities with increasing SEP quintiles (Q5: IRR 0.66, CI 0.41-1.06). Conclusion: Our findings underscore the complex epidemiological patterns of COVID-19, shaped by the interactions of gender/sex, SEP, and age, highlighting the need for intersectional perspectives in both epidemiological research and public health strategy development.

Out-of-pocket expenditures for primary health care in Tajikistan: a time-trend analysis.

BACKGROUND: Aligned with the international call for universal coverage of affordable and quality health care, the government of Tajikistan is undertaking reforms of its health system aiming amongst others at reducing the out-of-pocket expenditures (OPE) of patients seeking care. Household surveys were conducted in 2005, 2007, 2008 and 2011 to explore the scale and determinants of OPE of users in four district of Tajikistan, where health care is legally free of charge at the primary level. METHODS: Using the data from four cross-sectional household surveys conducted between 2005 and 2011, time trends in OPE for consultation fees, drugs and transport costs of adult users of family medicine services were analysed. To investigate differences along the economic status, an asset index was constructed using principal component analysis. RESULTS: Adjusted for inflation, OPE for primary care have substantially increased in the period 2005 to 2011. While the proportion of patients reporting the payment of informal consultation fees to providers and their amount were constant over time, the proportion of patients reporting expenditures for drugs has increased, and the median amounts have doubled from 5.3 US$ to 10.7 US$. Thus, the expenditures on medicine represent the biggest financial burden for patients accessing a primary care facility. Regression models showed that in 2011 patients from the most remote district with spread-out villages reported significant higher expenditures on medicine. Besides the steady increase in the median amount for OPE, the proportion of patients reporting making an informal payment to their care provider showed great variations across district of residence (between 20% and 73%) and economic status (between 33% among the 'worst-off' group and 68% among the 'better-off' group). CONCLUSIONS: In a context of limited governmental funds allocated to health and financing reforms aiming to improve financial access to primary care, the present paper indicates that in Tajikistan OPE - especially in relation to expenditures for drugs - have increased over time, and vary substantially across geographical areas and economic status. The fact that better-off households report disbursing more and in higher proportions hints towards a discrimination along the capacity to pay from providers. Increased public investments in the health sector, incentives for family doctors to provide PHC services free of charge and a strengthened drug control and supply system are necessary strategies to improve access of patients to services.

The level of the gender gap in academic publishing varies by country and region of affiliation: A cross-sectional study of articles published in general medical journals.

BACKGROUND: Women are generally under-represented as authors of publications, and especially as last authors, but this under-representation may not be uniformly distributed across countries. We aimed to document by country and region the proportion of female authors (PFA) in high-impact general medical journals. METHODS: We used PyMed, a Python library that provides access to PubMed, to retrieve all PubMed articles published between January 2012 and December 2021 in the fifty general internal medicine journals with the highest 2020 impact factor according to Journal Citation Reports. We extracted first/last authors' main country of affiliation for all these articles using regular expressions and manual search, and grouped the countries into eight regions (North/Latin America, Western/Eastern Europe, Asia, Pacific, Middle East, and Africa). We used NamSor to determine first/last authors' gender and computed the PFA for each country/region. RESULTS: We retrieved 163,537 publications for first authors and 135,392 for last authors. Gender could be determined for 160,891 and 133,373 publications, respectively. The PFA was 41% for first authors and 33% for last authors, but it varied widely by country (first authors: >50% for eight countries, maximum = 63% in Romania, minimum = 19% in Japan; last authors: >50% for two countries, maximum = 53% in Romania, minimum = 9% in Japan). The PFA also varied by region. It was highest for Eastern Europe (first authors = 53%, last authors = 40%), and lowest for Asia (36% and 29%) and the Middle East (35% and 27%). CONCLUSION: We found that the PFA varied widely by country and region, and was lowest in Asia, particularly Japan, and the Middle East. The under-representation of women as authors of publications, especially in these two regions, needs to be addressed and correcting persistent gender discrimination in research should be a top priority.

Exposure of medical students to sexism and sexual harassment and their association with mental health: a cross-sectional study at a Swiss medical school.

OBJECTIVES: To assess the self-reported prevalence of sexism and sexual harassment at a Swiss medical school, and to investigate their association with mental health. Research hypotheses were an association between sexism/sexual harassment and poor mental health and a higher prevalence of sexism/sexual harassment in clinical rotations. DESIGN: Cross-sectional study as a part of ETMED-L project, an ongoing cohort study of interpersonal competences and mental health of medical students. SETTING: Single-centre Swiss study using an online survey submitted to medical students. PARTICIPANTS: From 2096 registered students, 1059 were respondents (50.52%). We excluded 26 participants (25 due to wrong answers to attention questions, and 1 who did not answer the sexism exposure question). The final sample (N=1033) included 720 women, 300 men and 13 non-binary people. MEASURES: Prevalence of self-reported exposure to sexism/sexual harassment. Multivariate regression analyses of association between being targeted by sexism or sexual harassment and mental health (depression, suicidal ideation, anxiety, stress, burnout, substance use and recent mental health consultation). Regression models adjusted for gender, academic year, native language, parental education level, partnership and an extracurricular paid job. RESULTS: Being targeted by sexism or sexual harassment was reported by 16% of participants with a majority of women (96%). The prevalence increased with clinical work. After adjusting for covariates, we found association between being targeted by sexism/harassment and risk of depression (OR 2.29, 95% CI 1.54 to 3.41, p<0.001), suicidal ideation (B coefficient (B) 0.37, p<0.001) and anxiety (B 3.69, p<0.001), as well as cynicism (B 1.46, p=0.001) and emotional exhaustion (B 0.94, p=0.044) components of burnout, substance use (B 6.51, p<0.001) and a recent mental health consultation (OR 1.78, 95% CI 1.10 to 2.66, p=0.005). CONCLUSIONS: Sexism and sexual harassment, although less common than usually reported, are behaviours of concern in this medical school and are significantly associated with mental health.