Equity and Justice in Family Medicine Clinical Care and Teaching Must Incorporate a Reproductive Justice Framework.

Since European settlement, the United States has controlled the reproduction of communities of color through tactics ranging from forced pregnancies, sterilizations, and abortions to immigration policies and policies that separate children from their families. Lesbian, gay, bisexual, transgender, queer (or questioning), asexual, intersex, and gender diverse people (LGBTQIA+) have been persecuted for sexual behavior and gender expression, and also restricted from having children. In response, women of color and LGBTQIA+ communities have organized for Reproductive Justice (RJ) and liberation. The Reproductive Justice framework, conceived in 1994 by the Women of African Descent for Reproductive Justice, addresses the reproductive health needs of Black women and communities from a broad human rights perspective. Since then, the framework has expanded with an intersectional approach to include all communities of color and LGBTQIA+ communities. Notwithstanding, reproductive injustice negatively impacts the health of already marginalized and oppressed communities, which is reflected in higher rates of maternal mortality, infant mortality, infertility, preterm births, and poorer health outcomes associated with race-based stress. While the impact of racial injustice on disparate health outcomes is increasingly addressed in family medicine, Reproductive Justice has not been universally incorporated into care provision or education. Including the RJ framework in family medicine education is critical to understanding how structural, economic, and political factors influence health outcomes to improve health care delivery from a justice and human rights perspective. This commentary describes how an RJ framework can enhance medical education and care provision, and subsequently identifies strategies for incorporating Reproductive Justice teaching into family medicine education.

We Are Not All the Same: Implications of Heterogeneity Among Latiné/e/x/o/a, Hispanic, and Spanish Origin People.

There is great variation in the experiences of Latiné/e/x/o/a, Hispanic, and/or Spanish origin (LHS) individuals in the United States, including differences in race, ancestry, colonization histories, and immigration experiences. This essay calls readers to consider the implications of the heterogeneity of lived experiences among LHS populations, including variations in country of origin, immigration histories, time in the United States, languages spoken, and colonization histories on patient care and academia. There is power in unity when advocating for community, social, and political change, especially as it pertains to equity, diversity, and inclusion (EDI; sometimes referred to as DEI) efforts in academic institutions. Yet, there is also a critical need to disaggregate the LHS diaspora and its conceptualization based on differing experiences so that we may improve our understanding of the sociopolitical attributes that impact health. We propose strategies to improve recognition of these differences and their potential health outcomes toward a goal of health equity.

Examining Linguistic Differences in Electronic Health Records for Diverse Patients With Diabetes: Natural Language Processing Analysis.

Background: Individuals from minoritized racial and ethnic backgrounds experience pernicious and pervasive health disparities that have emerged, in part, from clinician bias. Objective: We used a natural language processing approach to examine whether linguistic markers in electronic health record (EHR) notes differ based on the race and ethnicity of the patient. To validate this methodological approach, we also assessed the extent to which clinicians perceive linguistic markers to be indicative of bias. Methods: In this cross-sectional study, we extracted EHR notes for patients who were aged 18 years or older; had more than 5 years of diabetes diagnosis codes; and received care between 2006 and 2014 from family physicians, general internists, or endocrinologists practicing in an urban, academic network of clinics. The race and ethnicity of patients were defined as White non-Hispanic, Black non-Hispanic, or Hispanic or Latino. We hypothesized that Sentiment Analysis and Social Cognition Engine (SEANCE) components (ie, negative adjectives, positive adjectives, joy words, fear and disgust words, politics words, respect words, trust verbs, and well-being words) and mean word count would be indicators of bias if racial differences emerged. We performed linear mixed effects analyses to examine the relationship between the outcomes of interest (the SEANCE components and word count) and patient race and ethnicity, controlling for patient age. To validate this approach, we asked clinicians to indicate the extent to which they thought variation in the use of SEANCE language domains for different racial and ethnic groups was reflective of bias in EHR notes. Results: We examined EHR notes (n=12,905) of Black non-Hispanic, White non-Hispanic, and Hispanic or Latino patients (n=1562), who were seen by 281 physicians. A total of 27 clinicians participated in the validation study. In terms of bias, participants rated negative adjectives as 8.63 (SD 2.06), fear and disgust words as 8.11 (SD 2.15), and positive adjectives as 7.93 (SD 2.46) on a scale of 1 to 10, with 10 being extremely indicative of bias. Notes for Black non-Hispanic patients contained significantly more negative adjectives (coefficient 0.07, SE 0.02) and significantly more fear and disgust words (coefficient 0.007, SE 0.002) than those for White non-Hispanic patients. The notes for Hispanic or Latino patients included significantly fewer positive adjectives (coefficient -0.02, SE 0.007), trust verbs (coefficient -0.009, SE 0.004), and joy words (coefficient -0.03, SE 0.01) than those for White non-Hispanic patients. Conclusions: This approach may enable physicians and researchers to identify and mitigate bias in medical interactions, with the goal of reducing health disparities stemming from bias.

Assessing the Knowledge and Comfort Level of US Family Medicine Residents Regarding Consenting and Confidentiality in Adolescent Health Care.

OBJECTIVES: Organizations recommend providing confidential adolescent health care to reduce the consequences of high-risk health behaviors such as substance use, unhealthy eating patterns, and high-risk sexual behaviors. Family physicians are uniquely positioned to provide confidential counseling and care to this vulnerable population but must be trained to provide such care. This study describes the impact of formal and informal training on the knowledge of and comfort level in providing confidential adolescent healthcare among a sample of US Family Medicine residents. METHODS: Electronic surveys were distributed to all Family Medicine residents throughout the United States. We used descriptive statistics and χ2 analysis where appropriate to determine the association between resident-reported receipt of training, confidence, and frequency in providing confidential adolescent health care. RESULTS: A total of 714 Family Medicine residents completed the survey. The majority reported no formal training in residency (50.3%). The receipt of formal and informal training in both medical school and residency was associated with a greater degree of comfort in providing confidential adolescent care and a higher likelihood of providing confidential time alone. Those reporting formal training were more likely to always provide confidential care (P = 0.001). CONCLUSIONS: Training focused on confidential adolescent health care in medical school or residency was associated with a greater degree of comfort and a higher likelihood of providing confidential adolescent health care.

Implications of Overturning Roe v Wade on Abortion Training in US Family Medicine Residency Programs.

In June 2022, the US Supreme Court overturned Roe v Wade, opening the door to state-level abortion bans. By August 2023, 17 states banned abortion or instituted early gestational age bans. We performed an analysis to assess the proportion of accredited US family medicine residency programs and trainees in states with abortion restrictions. Twenty-nine percent of family medicine residency programs (n = 201) and residents (n = 3,930) are in states with bans or very restrictive policies. Family medicine residency programs must optimize training and exposure to abortion within their contexts, so graduates are able to care for patients seeking abortions or needing follow-up care.

Provider perspectives on a point-of-care tool to facilitate patient-centered contraceptive care among Latina/x patients in Baltimore, MD.

Objectives: To explore clinician perspectives on the development, utility, and feasibility of a provider-facing point-of-care tool to assist in provision of patient-centered contraceptive care for Latina/x patients in Baltimore, MD. Methods: We conducted 25 semi-structured qualitative interviews with a sample of clinicians who provide contraceptive care to Latina/x patients. An interview guide was developed based on prior research related to patient-centered care and extant point-of-care tools. Transcripts were independently coded by two study team members and analyzed using a directed content analysis approach. Results: Four themes emerged from the data: (1) clinician perception of a need for a tool to facilitate patient-centered contraceptive care, (2) concern for tool burden and burnout, (3) desire for tool ease of use, and (4) a need for cultural awareness during tool development to avoid bias and typecasting. Conclusions: A provider-facing, point-of-care tool to facilitate patient-centered contraceptive counseling was acceptable among providers, provided the tool is easy to use and promotes cultural awareness. Innovation: In the current era of more limited reproductive choice across the U.S., the need and support for non-coercive, patient-centered contraceptive care is timely. A provider-facing, point-of-care tool can facilitate the provision of patient-centered care among clinicians proving contraceptive counseling to Latina/s.

"They Go Hand in Hand": Perspectives on the Relationship Between the Core Values of Family Medicine and Abortion Provision Among Family Physicians Who Do Not Oppose Abortion.

INTRODUCTION: Most family physicians do not provide abortion care, despite an apparent alignment between the defined values of family medicine and provision of abortion in primary care. This study seeks to understand how family physicians themselves perceive the relationship between their specialty's values and abortion provision. METHODS: We conducted in-depth interviews in 2019 with 56 family physicians who do not oppose abortion in the United States. We employed a deductive-inductive content analysis approach with memos to identify key themes. This analysis focuses on participants' beliefs in the core values of family medicine and how those values relate to abortion in family medicine. RESULTS: Participants identified and described six values of the specialty they prioritized, which included relationships, care across the lifespan, whole-person care, nonjudgmental care, meeting community needs, and social justice. Family physicians in the study overwhelmingly believed that abortion aligned with family medicine values, regardless of whether they themselves provided abortion care. CONCLUSIONS: Providing abortion care in primary care settings gives family physicians an opportunity to provide comprehensive care while improving access to meet community needs. As abortion care becomes increasingly restricted in the United States, family physicians can manifest the values of family medicine through integrating abortion care into their practices in states where abortion remains legal.

URiMs and Imposter Syndrome: Symptoms of Inhospitable Work Environments?

BACKGROUND AND OBJECTIVES: Workforce diversity is associated with improved health outcomes. Currently, primary care physicians who are underrepresented in medicine (URiM) disproportionately work in underserved areas. Increasingly, URiM faculty describe experiencing imposter syndrome (IS), including a sense of not belonging in their work environment and a lack of recognition. Studies of IS among family medicine faculty are not prevalent nor are the factors most associated with IS among URiMs and non-URiMs. The objectives of our study were to (1) determine prevalence of IS among URiM faculty compared to non-URiM faculty; (2) determine factors associated with IS among both URiM and non-URiM faculty. METHODS: Four hundred thirty participants completed anonymous, electronic surveys. We measured IS using a 20-item validated scale. RESULTS: Among all respondents, 43% reported frequent/intense IS. URiMs were not more likely than non-URiMs to report IS. Factors independently associated with IS for both URiM and non-URiM respondents include inadequate mentorship (P<.05) and poor professional belonging (P<.05). However, inadequate mentorship, low professional integration and belonging, and racial/ethnic discrimination-based exclusion from professional opportunities (all P<.05) were more prevalent among URiMs than non-URiMs. CONCLUSIONS: While URiMs are not more likely than non-URiMS to experience frequent/intense IS, they are more likely to report racial/ethnic discrimination, inadequate mentorship, and low professional integration and belonging. These factors are associated with IS and may be reflective of how institutionalized racism impedes mentorship and optimal professional integration, which may be internalized and perceived as IS among URiM faculty. Yet, URiM career success in academic medicine is crucial for achieving health equity.

Abortion Provision Among Family Physicians Underrepresented in Medicine.

BACKGROUND AND OBJECTIVES: Workforce diversity in primary care is critical for improved health outcomes and mitigation of inequities. However, little is known about the racial and ethnic identities, training histories, and practice patterns of family physicians who provide abortions. METHODS: Family physicians who graduated from residency programs with routine abortion training from 2015 through 2018 completed an anonymous electronic cross-sectional survey. We measured abortion training, intentions to provide abortion, and practice patterns, and examined differences between underrepresented in medicine (URM) and non-URM physicians using χ2 tests and binary logistic regression. RESULTS: Two hundred ninety-eight respondents completed the survey (39% response rate), 17% of whom were URM. Similar percentages of URM and non-URM respondents had abortion training and had intended to provide abortions. However, fewer URMs reported providing procedural abortion in their postresidency practice (6% vs 19%, P=.03) and providing abortion in the past year (6% vs 20%, P=.023). In adjusted analyses, URMs were less likely to have provided abortions after residency (OR=.383, P=.03) and in the past year (OR=.217, P=.02) compared to non-URMs. Of the 16 noted barriers to provision, few differences were evident between groups on the indicators measured. CONCLUSIONS: Differences in postresidency abortion provision existed between URM and non-URM family physicians despite similar training and intentions to provide. Examined barriers do not explain these differences. Further research on the unique experiences of URM physicians in abortion care is needed to then consider which strategies for building a more diverse workforce should be employed.

Provider perspectives on patient-centered contraceptive counseling for Latinas in Baltimore, MD.

OBJECTIVES: To explore: 1) provider narratives of their contraceptive counseling practices with Latina patients within the context of patient-centered care (PCC); and 2) provider perceptions about the barriers to the provision of patient-centered contraceptive counseling in general and more specifically, with Latina patients in Baltimore, MD. STUDY DESIGN: We conducted 25 semistructured qualitative interviews with physicians  and nurse practitioners from four specialties who provide contraceptive care to Latinas in Baltimore, MD. We analyzed data using directed content analysis. We discuss findings with attention to major constructs of PCC, applying a reproductive justice framework. RESULTS: Providers described a contraceptive counseling approach focused on pregnancy prevention as the primary goal. Most respondents used a tiered-effectiveness approach, even while noting the importance of PCC. Providers noted health system barriers to PCC, including time constraints and insurance status. Provider-reported patient-attributed barriers included low patient education/health literacy, culturally-attributed misconceptions about contraception, and language discordance. CONCLUSION: Providers described knowledge of and intention to practice PCC but had limited integration of it in their own counseling with Latinas. Responses suggest tension between an expressed desire to provide PCC and paternalistic counseling paradigms that prioritize pregnancy prevention over patient preferences. Inequitable health system barriers also interfere with true implementation of contraceptive PCC. IMPLICATIONS: Translating contraceptive PCC into practice, especially for marginalized communities, is paramount. Training should teach clinicians to recognize systems of structural inequity and discrimination that have informed approaches to counseling but are not reflective of PCC. Institutional policies must address health system barriers that also hamper PCC.

Addressing and Dismantling the Legacy of Race and Racism in Academic Medicine: A Socioecological Framework.

Over the past several years, in both clinical and academic medicine, there seems to be a growing consensus that racial/ethnic health inequities result from social, economic and political determinants of health rather than from nonexistent biological markers of race. Simply put, racism is the root cause of inequity, not race. Yet, methods of teaching and practicing medicine have not kept pace with this truth, and many learners and practitioners continue to extrapolate a biological underpinning for race. To achieve systemic change that moves us toward racially/ethnically equitable health outcomes, it is imperative that medical academia implement policies that explicitly hold us accountable to maintain a clear understanding of race as a socio-political construct so that we can conduct research, disseminate scholarly work, teach, and practice clinically with more clarity about race and racism. This short commentary proposes the use of a socioecological framework to help individuals, leadership teams, and institutions consider the implementation of various strategies for interpersonal, community-level, and broad institutional policy changes. This proposed model includes examples of how to address race and racism in academic medicine across different spheres, but also draws attention to the complex interplay across these levels. The model is not intended to be prescriptive, but rather encourages adaptation according to existing institutional differences. This model can be used as a tool to refresh how academic medicine addresses race and, more importantly, normalizes conversations about racism and equity across all framework levels.

Contraceptive Decision-Making and the Importance of Side Effect Information Among a Sample of Latinas.

Context: U.S. Latinas have lower rates of contraceptive use and report more negative counseling experiences compared to non-Latina white women. Patient-centered approaches to contraceptive counseling are desired among Latinas and are also associated with patient satisfaction; yet, clinicians may not always use counseling methods that best support decision-making among marginalized groups. Objective: To examine Latinas' expectations of physician communication about contraceptive side effects, reported importance of personal knowledge about side effects, and the association of these with contraceptive use and use consistency. Materials and Methods: One hundred three self-identified Latinas aged 15-29 years at two urban federally qualified health centers completed a survey measuring factors associated with contraceptive use and consistency. Bivariate analysis was used to assess demographic and contraceptive information preferences. Associations between categorical variables were assessed using two-sided Fisher's exact tests. Continuous variables were compared using two-sided t-test. Results: The majority of respondents (85%) expected physicians to tell them about birth control side effects and reported that this information is important to use contraception, regardless of current contraceptive use. Among inconsistent and nonusers, importance of knowledge of side effects depended on expectations of information-sharing from physicians (p < 0.05). Conclusions: Expectations regarding side effect information-sharing by physicians and patient knowledge of side effects are important for the contraceptive decision-making process of this Latina group, regardless of contraceptive use. Clinicians engaging in contraceptive counseling should focus on providing clear and accurate information about side effects of discussed methods to facilitate informed decision-making and equitable, patient-centered contraceptive care for this vulnerable population.

Expert Perspectives on Effective Community-Based Pediatric Healthcare for Low-Income Latino Families: Persistent Issues over Time.

US Latinos continue to experience significant health inequity, despite fluctuating healthcare policies over the past 20 years. Recent studies highlight the importance of comprehensive care and collaboration of stakeholders in reducing inequity. Few studies examine the perspectives of community-based organization leaders, health researchers, and policy experts regarding the most effective practices in the delivery of healthcare to Latino children and families. This unique study employed a mixed-methods cross-sectional design to compare perceptions of effective practices and action strategies among two groups. Analysis of qualitative data gathered from 17 organizational leaders and 28 research/policy experts resulted in four broad themes: (1) engagement of families as participants in their healthcare; (2) provision of comprehensive, family-focused healthcare services across the lifespan; (3) engagement of ethnically competent staff to provide outreach; and (4) development of community collaborations for resource building. Respondents identified three major barriers to the provision of high-quality care: (1) inequities in social determinants; (2) ongoing changes in insurance coverage; and (3) funding challenges for the support of community-based health centers (CHCs). Although the data were collected in 2001, these thematic findings remain relevant given the persistence of inequities and the lack of progress in mitigating inequity among Latino children and families, despite evolving healthcare system changes. The study conclusions reaffirm the importance of community-driven preventive healthcare services across the life course. These community services are the frontline of healthcare for many Latino children and their families; therefore, their sustainability is crucial. The voices of organizational leaders, health research, and policy experts are important and relevant.

Latina contraceptive decision-making and use: The importance of provider communication and shared decision-making for patient-centered care.

BACKGROUND: Poor patient-provider communication, among other reasons, is a notable barrier to contraceptive decision-making among Latinas. Patient-centered approaches to contraceptive counseling that optimize communication align with shared decision-making (SDM) -which is associated with satisfaction and continued contraceptive use among various populations. OBJECTIVE: To examine associations of patient-provider communication and importance of SDM tenets with consistent contraceptive use among a population of Latinas. PATIENT INVOLVEMENT: Formative work for this study included prior qualitative and quantitative research with Latinas who expressed the importance of patient-provider communication during contraceptive counseling and therefore were instrumental in problem definition. METHODS: Cross-sectional surveys were administered to Latinas ages 15-29 years. Patient-provider communication, patient-reported importance of specific SDM tenets, and consistent contraception use were measured and analyzed for associations. RESULTS: 103 Latinas (mean age = 21.4) participated. 33% of participants<21 years were using contraception consistently vs. 67% for those ≥ 21 (p = 0.003). Among participants ≥ 21, consistent users reported higher communication scores compared to inconsistent users and non-users (p = 0.042). For participants< 21, consistent users were more likely than inconsistent users and non-users to report that 2 SDM tenets (discussion of contraceptive preferences and avoidance of race/ethnic-based judgement) are important (p = 0.052, 0.028, respectively). DISCUSSION: Patient-provider communication was especially important for Latinas ≥ 21 while using an SDM approach during counseling was highly valued by those<21. Patient-centered approaches to contraceptive counseling provide opportunities to optimize healthcare delivery for this vulnerable population. PRACTICAL VALUE: Results from this research demonstrate that patient-centered communication is highly valued by Latina study participants and is an important consideration in their contraceptive counseling. Clinicians should consider employing techniques such as SDM as they seek to provide patient-centered care during contraceptive counseling for this patient population.

Dear White People.

We are living in unprecedented times. While the world is grappling with COVID-19, we find the horrors of racism looming equally large as we, yet again, confront lurid deaths in the center of the news cycle of Black and brown people from police bias and brutality. Those of us who have been championing antiracism and justice work and bearing the burden of the "minority tax" have been overwhelmed by sudden asks from our well-intentioned White colleagues of how to best respond. In the tone of the Netflix series, "Dear White People," we further emphasize that we are not alone in trying to reach out to you, our White colleagues and leaders. Please hear our story and heed our call to action.

Challenging Stereotypes: A Counter-Narrative of the Contraceptive Experiences of Low-Income Latinas.

Purpose: Reproductive autonomy is associated with educational attainment, advanced employment, and well-being. While U.S. Latinas use contraception to control their own childbearing and have reported a desire to do so, they often use it inconsistently and have the lowest rates of contraceptive use of any group. Reasons previously cited for why Latinas do not use contraception compared with non-Latino white women include lack of access, lack of knowledge, language barriers, emphasis on large families, machismo, and religiosity. These reasons are often overly simplistic and can lead to widespread generalizations about Latinas. Methods: Using focus groups and semistructured interviews from November 2014 through June 2015, this study describes the family planning perspectives and experiences of 16 Latinas living in Baltimore and recruited from two federally qualified health centers. A social determinant of health framework was used to guide identification of important concepts and explain findings. Results: Results demonstrated that respondents reported contraceptive agency and claimed autonomy over their bodies; described a sense of responsibility and often expressed caution about having families too large to care for; expressed educational and career aspirations; and perceived contraception as critical for the postponement of childbearing to achieve their goals. Conclusion: The patient/provider encounter should include communication that recognizes all patient preferences and lived experiences to support vulnerable and/or marginalized Latinas in their desires to control their own childbearing and life choices.

Patient perceptions of immediate postpartum long-acting reversible contraception: A qualitative study.

OBJECTIVES: The objective of this study was to explore perceptions and experiences of immediate postpartum long-acting reversible contraception (LARC) counseling and decision-making, with a focus on reproductive autonomy. We aimed to assess the potential for reproductive coercion. STUDY DESIGN: This was a qualitative study using semi-structured interviews with Spanish and English speaking women who received an intrauterine device or contraceptive subdermal implant immediately postpartum. They were recruited before discharge from two hospitals in Baltimore, MD. We analyzed interviews using directed content analysis. RESULTS: We interviewed a diverse group of 17 women. Participants praised the convenience of LARC and the ease of immediate postpartum placement. Some women reported feeling pushed by providers during counseling and were critical of their experiences. Women expressed a desire for comprehensive, objective information early and often during antepartum contraceptive counseling, and some valued counseling from multiple providers. They wanted autonomy in their contraceptive decision-making and described making internally motivated decisions based on their life goals and individual priorities. CONCLUSIONS: Some women felt pressured to choose immediate postpartum LARC, while others expressed enthusiasm for immediate postpartum LARC. Our data suggest that providers should start contraceptive counseling early in prenatal care and readdress it at multiple visits. Patients may benefit from speaking with multiple providers. IMPLICATIONS: Our study supports immediate postpartum LARC as a favorable contraceptive option for some women when discussed during prenatal care. Providers should take care to avoid coercion during counseling and focus on delivering comprehensive, objective information about all contraceptive methods, including side effects and removal options.

Contraceptive Decision Making Among Latina Immigrants: Developing Theory-Based Survey Items.

BACKGROUND: Contraception is important for reproductive autonomy, yet many Latinas do not use contraception consistently despite research reporting a desire to do so. Factors varying in priority and value come into play during contraceptive decision making. When measuring these, relevant survey items may vary by populations. AIM: This study focused on developing an ethnically responsive, patient-centered, content-valid survey for measuring factors that influence contraceptive decision making among immigrant Latinas. METHOD: Nonpregnant self-identified Latinas ages 15 to 24 years in Baltimore, MD, were recruited from a family planning facility. Using the theory of planned behavior as a theoretical framework and prior formative research, initial survey items were drafted (Step 1). Content validation and cognitive interviewing procedures (Step 2 and Step 3) were used to develop final items. RESULTS: Final items (27) were content-validated by the target population; items reflect important factors and relevant contexts affecting contraceptive decision making among Latinas in Baltimore. DISCUSSION: These theory-based items provide an important contribution to the literature because they measure and explore factors related to contraceptive decision making in an understudied population. Providers might consider these factors during counseling to build patient-centered communication. These items might serve to measure responses to theory of planned behavior-based interventions designed to improve the contraceptive counseling of Latinas.