Workplace Harassment, Cyber Incivility, and Climate in Academic Medicine.

Importance: The culture of academic medicine may foster mistreatment that disproportionately affects individuals who have been marginalized within a given society (minoritized groups) and compromises workforce vitality. Existing research has been limited by a lack of comprehensive, validated measures, low response rates, and narrow samples as well as comparisons limited to the binary gender categories of male or female assigned at birth (cisgender). Objective: To evaluate academic medical culture, faculty mental health, and their relationship. Design, Setting, and Participants: A total of 830 faculty members in the US received National Institutes of Health career development awards from 2006-2009, remained in academia, and responded to a 2021 survey that had a response rate of 64%. Experiences were compared by gender, race and ethnicity (using the categories of Asian, underrepresented in medicine [defined as race and ethnicity other than Asian or non-Hispanic White], and White), and lesbian, gay, bisexual, transgender, queer (LGBTQ+) status. Multivariable models were used to explore associations between experiences of culture (climate, sexual harassment, and cyber incivility) with mental health. Exposures: Minoritized identity based on gender, race and ethnicity, and LGBTQ+ status. Main Outcomes and Measures: Three aspects of culture were measured as the primary outcomes: organizational climate, sexual harassment, and cyber incivility using previously developed instruments. The 5-item Mental Health Inventory (scored from 0 to 100 points with higher values indicating better mental health) was used to evaluate the secondary outcome of mental health. Results: Of the 830 faculty members, there were 422 men, 385 women, 2 in nonbinary gender category, and 21 who did not identify gender; there were 169 Asian respondents, 66 respondents underrepresented in medicine, 572 White respondents, and 23 respondents who did not report their race and ethnicity; and there were 774 respondents who identified as cisgender and heterosexual, 31 as having LGBTQ+ status, and 25 who did not identify status. Women rated general climate (5-point scale) more negatively than men (mean, 3.68 [95% CI, 3.59-3.77] vs 3.96 [95% CI, 3.88-4.04], respectively, P < .001). Diversity climate ratings differed significantly by gender (mean, 3.72 [95% CI, 3.64-3.80] for women vs 4.16 [95% CI, 4.09-4.23] for men, P < .001) and by race and ethnicity (mean, 4.0 [95% CI, 3.88-4.12] for Asian respondents, 3.71 [95% CI, 3.50-3.92] for respondents underrepresented in medicine, and 3.96 [95% CI, 3.90-4.02] for White respondents, P = .04). Women were more likely than men to report experiencing gender harassment (sexist remarks and crude behaviors) (71.9% [95% CI, 67.1%-76.4%] vs 44.9% [95% CI, 40.1%-49.8%], respectively, P < .001). Respondents with LGBTQ+ status were more likely to report experiencing sexual harassment than cisgender and heterosexual respondents when using social media professionally (13.3% [95% CI, 1.7%-40.5%] vs 2.5% [95% CI, 1.2%-4.6%], respectively, P = .01). Each of the 3 aspects of culture and gender were significantly associated with the secondary outcome of mental health in the multivariable analysis. Conclusions and Relevance: High rates of sexual harassment, cyber incivility, and negative organizational climate exist in academic medicine, disproportionately affecting minoritized groups and affecting mental health. Ongoing efforts to transform culture are necessary.

Discriminatory attitudes against unvaccinated people during the pandemic.

During the COVID-19 pandemic, sizeable groups of unvaccinated people persist even in countries with high vaccine access1. As a consequence, vaccination became a controversial subject of debate and even protest2. Here we assess whether people express discriminatory attitudes in the form of negative affectivity, stereotypes and exclusionary attitudes in family and political settings across groups defined by COVID-19 vaccination status. We quantify discriminatory attitudes between vaccinated and unvaccinated citizens in 21 countries, covering a diverse set of cultures across the world. Across three conjoined experimental studies (n = 15,233), we demonstrate that vaccinated people express discriminatory attitudes towards unvaccinated individuals at a level as high as discriminatory attitudes that are commonly aimed at immigrant and minority populations3-5. By contrast, there is an absence of evidence that unvaccinated individuals display discriminatory attitudes towards vaccinated people, except for the presence of negative affectivity in Germany and the USA. We find evidence in support of discriminatory attitudes against unvaccinated individuals in all countries except for Hungary and Romania, and find that discriminatory attitudes are more strongly expressed in cultures with stronger cooperative norms. Previous research on the psychology of cooperation has shown that individuals react negatively against perceived 'free-riders'6,7, including in the domain of vaccinations8,9. Consistent with this, we find that contributors to the public good of epidemic control (that is, vaccinated individuals) react with discriminatory attitudes towards perceived free-riders (that is, unvaccinated individuals). National leaders and vaccinated members of the public appealed to moral obligations to increase COVID-19 vaccine uptake10,11, but our findings suggest that discriminatory attitudes-including support for the removal of fundamental rights-simultaneously emerged.

Social capital II: determinants of economic connectedness.

Low levels of social interaction across class lines have generated widespread concern1-4 and are associated with worse outcomes, such as lower rates of upward income mobility4-7. Here we analyse the determinants of cross-class interaction using data from Facebook, building on the analysis in our companion paper7. We show that about half of the social disconnection across socioeconomic lines-measured as the difference in the share of high-socioeconomic status (SES) friends between people with low and high SES-is explained by differences in exposure to people with high SES in groups such as schools and religious organizations. The other half is explained by friending bias-the tendency for people with low SES to befriend people with high SES at lower rates even conditional on exposure. Friending bias is shaped by the structure of the groups in which people interact. For example, friending bias is higher in larger and more diverse groups and lower in religious organizations than in schools and workplaces. Distinguishing exposure from friending bias is helpful for identifying interventions to increase cross-SES friendships (economic connectedness). Using fluctuations in the share of students with high SES across high school cohorts, we show that increases in high-SES exposure lead low-SES people to form more friendships with high-SES people in schools that exhibit low levels of friending bias. Thus, socioeconomic integration can increase economic connectedness in communities in which friending bias is low. By contrast, when friending bias is high, increasing cross-SES interactions among existing members may be necessary to increase economic connectedness. To support such efforts, we release privacy-protected statistics on economic connectedness, exposure and friending bias for each ZIP (postal) code, high school and college in the United States at https://www.socialcapital.org .

Measuring dynamic media bias.

Ideological media bias is increasingly central to the study of politics. Yet, past literature often assumes that the ideological bias of any outlet, at least in the short term, is static and exogenous to the political process. We challenge this assumption. We use longitudinal data from the Stanford Cable News Analyzer (2010 to 2021), which reports the screen time of various political actors on cable news, and quantify the partisan leaning of those actors using their past campaign donation behavior. Using one instantiation of media bias-the mean ideology of political actors on a channel, i.e., visibility bias-we examine weekly, within-day, and program-level estimates of media bias. We find that media bias is highly dynamic even in the short term and that the heightened polarization between TV channels over time was mostly driven by the prime-time shows.

Unobtrusive measures of prejudice: Estimating percentages of public beliefs and behaviours.

This study was concerned with how accurate people are in their knowledge of population norms and statistics concerning such things as the economic, health and religious status of a nation and how those estimates are related to their own demography (e.g age, sex), ideology (political and religious beliefs) and intelligence. Just over 600 adults were asked to make 25 population estimates for Great Britain, including religious (church/mosque attendance) and economic (income, state benefits, car/house ownership) factors as well as estimates like the number of gay people, immigrants, smokers etc. They were reasonably accurate for things like car ownership, criminal record, vegetarianism and voting but seriously overestimated numbers related to minorities such as the prevalence of gay people, muslims and people not born in the UK. Conversely there was a significant underestimation of people receiving state benefits, having a criminal record or a private health insurance. Correlations between select variables and magnitude and absolute accuracy showed religiousness and IQ most significant correlates. Religious people were less, and intelligent people more, accurate in their estimates. A factor analysis of the estimates revealed five interpretable factors. Regressions were calculated onto these factors and showed how these individual differences accounted for as much as 14% of the variance. Implications and limitations are acknowledged.

Discrimination and Subsequent Mental Health, Substance Use, and Well-being in Young Adults.

OBJECTIVES: Discrimination has been shown to have profound negative effects on mental and behavioral health and may influence these outcomes early in adulthood. We aimed to examine short-term, long-term, and cumulative associations between different types of interpersonal discrimination (eg, racism, sexism, ageism, and physical appearance discrimination) and mental health, substance use, and well-being for young adults in a longitudinal nationally representative US sample. METHODS: We used data from 6 waves of the Transition to Adulthood Supplement (2007-2017, 1834 participants) of the Panel Study of Income Dynamics. Outcome variables included self-reported health, drug use, binge drinking, mental illness diagnosis, Languishing and Flourishing score, and Kessler Psychological Distress Scale score. We used logistic regression with cluster-robust variance estimation to test cross-sectional and longitudinal associations between discrimination frequency (overall, cumulative, and by different reason) and outcomes, controlling for sociodemographics. RESULTS: Increased discrimination frequency was associated with higher prevalence of languishing (relative risk [RR] 1.34 [95% CI 1.2-1.4]), psychological distress (RR 2.03 [95% CI 1.7-2.4]), mental illness diagnosis (RR 1.26 [95% CI 1.1-1.4]), drug use (RR 1.24 [95% CI 1.2-1.3]), and poor self-reported health (RR 1.26 [95% CI 1.1-1.4]) in the same wave. Associations persisted 2 to 6 years after exposure to discrimination. Similar associations were found with cumulative high-frequency discrimination and with each discrimination subcategory in cross-sectional and longitudinal analyses. CONCLUSIONS: In this nationally representative longitudinal sample, current and past discrimination had pervasive adverse associations with mental health, substance use, and well-being in young adults.

Workplace discrimination as risk factor for long-term sickness absence: Longitudinal analyses of onset and changes in workplace adversity.

Workplace discrimination may affect the health of the exposed employees, but it is not known whether workplace discrimination is also associated with an increased risk of long-term sickness absence. The aim of this study was to examine the longitudinal associations of changes in and onset of workplace discrimination with the risk of long-term sickness absence. Data on workplace discrimination were obtained from 29,597 employees participating in survey waves 2004, 2006, 2008 and/or 2010 of the Finnish Public Sector Study. Four-year changes in long-term sickness absence (≥10 days of medically certified absence with a mental or non-mental diagnosis) were assessed. This covered successive study waves in analyses of onset of workplace discrimination as well as fixed effect analyses of change in workplace discrimination (concurrent i.e. during the exposure year and 1-year lagged i.e. within one year following exposure), by using each employee as his/her own control. The risk of long-term sickness absence due to mental disorders was greater for employees with vs. without onset of workplace discrimination throughout the 4-year period, reaching a peak at the year when the onset of discrimination was reported (adjusted risk ratio 2.13; 95% confidence interval (CI) 1.80-2.52). The fixed effects analyses showed that workplace discrimination was associated with higher odds of concurrent, but not 1-year lagged, long-term sickness absence due to mental disorders (adjusted odds ratio 1.61; 95% CI 1.33-1.96 and adjusted odds ratio 1.02; 95% CI 0.83-1.25, respectively). Long-term sickness absence due to non-mental conditions was not associated with workplace discrimination. In conclusion, these findings suggest that workplace discrimination is associated with an elevated risk of long-term sickness absence due to mental disorders. Supporting an acute effect, the excess risk was confined to the year when workplace discrimination occurred.

Project Inclusive Genetics: Exploring the impact of patient-centered counseling training on physical disability bias in the prenatal setting.

PURPOSE: There is robust research examining the negative impact of racial and socioeconomic implicit bias on healthcare provider clinical decision-making. However, other under-studied important biases are likely to impact clinical care as well. The goal of this study was to explore the presence of bias against people with physical disability among a heterogeneous group of healthcare workers and trainees and to evaluate the effect of implicit association testing and an educational module on this bias. METHOD: The study was composed of a one-hour web-based survey and educational module. The survey included an explicit disability bias assessment, disability Implicit Association Tests (IATs), demographic collection, and pre- and post- module clinical vignettes of prenatal patient scenarios. In addition to providing counseling to hypothetical patients, participants also indicated their personal preferences on genetic testing and termination. The educational module focused on the principles of patient-centered counseling. RESULTS: The collected data reflects responses from 335 participants. Within this sample, there were both explicit and implicit biases towards individuals with physical disabilities. Prior to the IAT and educational module, when respondents were tasked with providing genetic testing recommendations, implicit biases and personal preferences for genetic testing and termination influenced respondents' clinical recommendations. Importantly, having previous professional experience with individuals with disabilities diminished biased clinical recommendations prior to the intervention. In response to the IAT and educational intervention, the effect of implicit bias and personal preferences on clinical recommendations decreased. CONCLUSIONS: This study demonstrates how bias against a marginalized group exists within the medical community and that personal opinions can impact clinical counseling. Importantly, our findings suggest that there are strategies that can be easily implemented into curricula to address disability bias, including formal educational interventions and the addition of professional experiences into healthcare professional training programs.

The onset of COVID-19, common identity, and intergroup prejudice.

The research presented here examined the relationship between the onset of the COVID-19 pandemic, social group identity, intergroup contact, and prejudice. Utilizing a common ingroup identity approach, two datasets, which were composed of data from university students collected via online questionnaires before and after the onset of COVID-19, were combined (N = 511). Participants identified as either one of two subordinate student identities: domestic (i.e. U.S. citizen or permanent resident) or international (i.e. non-U.S. citizen or foreign resident), then reported on the strength of their subordinate and superordinate identity (university identity). Participants also reported on their contact experiences with outgroup members, outgroup stereotypes, and completed a novel intergroup bias task. Results indicated that after the onset of the pandemic, participants more strongly identified with the superordinate group, which predicted greater perceived intergroup contact and lower intergroup bias. Theoretical implications and future directions are discussed.

COVID-19 and prejudice against migrants: the mediating roles of need for cognitive closure and binding moral foundations. A comparative study.

What mitigates prejudice against migrants in situations of uncertainty? Addressing this question, we explored how individuals with greater COVID-19 concern perceive migrants as a greater threat and show prejudice against them, indirectly through the mechanism of need for cognitive closure and binding moral foundations.This study was conducted in two European countries: Malta and Italy. Six hundred and seventy-six individuals participated in this quantitative study (Malta: N = 204; Italy N = 472). Results from this study showed that the need for cognitive closure and binding moral foundations mediate the relationship between COVID-19 concern and prejudice against migrants in both countries. When testing the three binding moral foundations (loyalty, authority, and purity), the authority foundation seems to be the most consistent predictor.The implications of the findings contribute to theories about how situational uncertainty caused by COVID-19, together with the need for epistemic certainty and binding morality, contribute to increased prejudiced attitudes against migrants.

Violence and discrimination among Ugandan residents during the COVID-19 lockdown.

BACKGROUND: In March 2020, the World Health Organization (WHO) declared COVID-19 a pandemic. Many countries in Sub-Saharan Africa, Uganda inclusive, implemented lockdowns, curfew, banning of both private and public transport systems, and mass gatherings to minimize spread. Social control measures for COVID-19 are reported to increase violence and discrimination globally, including in Uganda as some may be difficult to implement resulting in the heavy deployment of law enforcement. Media reports indicated that cases of violence and discrimination had increased in Uganda's communities following the lockdown. We estimated the incidence and factors associated with experiencing violence and discrimination among Ugandans during the COVID-19 lockdown to inform control and prevention measures. METHODS: In April 2020, we conducted a secondary analysis of cross-sectional data under the International Citizen Project (ICP) to assess adherence to public health measures and their impact on the COVID-19 outbreak in Uganda. We analyzed data on violence and discrimination from the ICP study. We performed descriptive statistics for all the participants' characteristics and created a binary outcome variable called experiencing violence and/or discrimination. We performed logistic regression analysis to identify the factors associated with experiencing violence and discrimination. RESULTS: Of the 1726 ICP study participants, 1051 (58.8%) were males, 841 (48.7%) were currently living with a spouse or partner, and 376 (21.8%) had physically attended work for more than 3 days in the past week. Overall, 145 (8.4%) experienced any form of violence and/or discrimination by any perpetrator, and 46 (31.7%) of the 145 reported that it was perpetrated by a law enforcement officer. Factors associated with experiencing violence or discrimination were: being male (AOR = 1.60 CI:1.10-2.33), having attended work physically for more than 3 days in the past week (AOR = 1.52 CI:1.03-2.23), and inability to access social or essential health services since the epidemic started (AOR = 3.10 CI:2.14-4.50). CONCLUSION: A substantial proportion of Ugandan residents experienced violence and/or discrimination during the COVID-19 lockdown, mostly perpetrated by law enforcement officers. We recommend mitigation of the collateral impact of lockdowns with interventions that focus on improving policing quality, ensuring continuity of essential services, and strengthening support systems for vulnerable groups including males.

Impact of socio-economic inequity in access to maternal health benefits in India: Evidence from Janani Suraksha Yojana using NFHS data.

BACKGROUND: Caste plays a significant role in Indian society and it influences women to health care access in the community. The implementation of the maternal health benefits scheme in India is biased due to caste identity. In this context, the paper investigates access to Janani Suraksha Yojana (JSY) among social groups to establish that caste still plays a pivotal role in Indian society. Also, this paper aims to quantify the discrimination against Scheduled Castes/Scheduled Tribes (SCs/STs) in accessing JSY. METHODS: This paper uses a national-level data set of both NFHS-3 (2005-06) and NFHS-4 (2015-16). Both descriptive statistics and the Fairlie decomposition econometric model have been used to measure the explained and unexplained differences in access to JSY between SCs/STs and non-SCs/STs groups. RESULTS: Overall, the total coverage of JSY in India is still, 36.4%. Further, it is found that 72% of access to JSY is explained by endowment variables. The remaining unexplained percentage (28%) indicates that there is caste discrimination (inequity associated social-discrimination) against SCs/STs in access to JSY. The highest difference (54%) between SCs/STs and non-SCs/STs in access to JSY comes from the wealth quintile, with the positive sign indicating that the gap between the two social groups is widening. DISCUSSION AND CONCLUSION: It is necessary for the government to implement a better way to counter the caste-based discrimination in access to maternal health benefits scheme. In this regard, ASHA and Anganwadi workers must be trained to reduce the influence of dominant caste groups as well as they must be recruited from the same community to identify the right beneficiaries of JSY and in order to reduce inequity associated with social-discrimination.

A qualitative study of barriers to employment experienced by people living with HIV in Toronto and Ottawa.

BACKGROUND: Effective treatment has extended the life expectancy and reduced disability in people living with HIV (PLWH). However, previous research has found 45-65% of working-age PLWH were unemployed compared to 5-10% in the general public of North America and Europe. We examined the barriers to gaining employment among PLWH. METHODS: Thirty-five in-depth interviews were conducted in person or over the phone with PLWH living in Toronto or Ottawa. This included PLWH who were unemployed but actively seeking employment, as well as PLWH who had successfully gained employment through an agency that specifically supported PLWH funded by the AIDS Committee of Toronto. Interviews were conducted between February 2019 and March 2020. All interviews were audio-recorded, transcribed and analyzed using thematic analysis. RESULTS: The majority of participants were between the ages of 40-55 and identified as male. Participants shared many common barriers when describing their attempts to attain or maintain employment. Although varying in employment status at the time of the study, consistent barriers included experiencing HIV stigma in workplaces, challenges overcoming mental health illnesses, and difficulties in navigating social assistance and unemployment insurance programs when pursuing a return to work. CONCLUSIONS: PLWH face significant barriers when attempting to engage with employment opportunities. Health providers and organizations can do more to support campaigns to end HIV stigma, to support individuals in pursuing employment, and to advocate for policy change that supports reentry into the workforce for PLHA.

Monitoring hiring discrimination through online recruitment platforms.

Women (compared to men) and individuals from minority ethnic groups (compared to the majority group) face unfavourable labour market outcomes in many economies1,2, but the extent to which discrimination is responsible for these effects, and the channels through which they occur, remain unclear3,4. Although correspondence tests5-in which researchers send fictitious CVs that are identical except for the randomized minority trait to be tested (for example, names that are deemed to sound 'Black' versus those deemed to sound 'white')-are an increasingly popular method to quantify discrimination in hiring practices6,7, they can usually consider only a few applicant characteristics in select occupations at a particular point in time. To overcome these limitations, here we develop an approach to investigate hiring discrimination that combines tracking of the search behaviour of recruiters on employment websites and supervised machine learning to control for all relevant jobseeker characteristics that are visible to recruiters. We apply this methodology to the online recruitment platform of the Swiss public employment service and find that rates of contact by recruiters are 4-19% lower for individuals from immigrant and minority ethnic groups, depending on their country of origin, than for citizens from the majority group. Women experience a penalty of 7% in professions that are dominated by men, and the opposite pattern emerges for men in professions that are dominated by women. We find no evidence that recruiters spend less time evaluating the profiles of individuals from minority ethnic groups. Our methodology provides a widely applicable, non-intrusive and cost-efficient tool that researchers and policy-makers can use to continuously monitor hiring discrimination, to identify some of the drivers of discrimination and to inform approaches to counter it.

Association between maternity harassment and depression during pregnancy amid the COVID-19 state of emergency.

OBJECTIVES: Maternity harassment, known in English as pregnancy discrimination, remains prevalent in developed countries. However, research examining the mental health effects of maternity harassment is lacking. We aimed to examine the association between maternity harassment and depression during pregnancy in Japan. METHODS: A cross-sectional Internet survey was conducted on 359 pregnant employees (including women who were working at the time their pregnancy was confirmed) from May 22 to May 31, 2020, during which time a COVID-19 state of emergency was declared. Maternity harassment was defined as being subjected to any of the 16 adverse treatments prohibited by national guidelines. Depression was defined as a score of ≥9 on the Edinburgh Postnatal Depression Scale (Japanese version). Logistic regression analysis was performed. RESULTS: Overall, 24.8% of the pregnant employees had experienced maternity harassment by supervisors and/or colleagues. After adjusting for demographics, pregnancy status, work status, and fear of COVID-19, pregnant employees who experienced maternity harassment were more likely to have depression than those who did not (odds ratio 2.48, 95% confidential interval 1.34-4.60). This association was not influenced by whether they were teleworking or not as a COVID-19 measure. CONCLUSIONS: One quarter of pregnant employees experienced maternity harassment and had a higher prevalence of depression than those who did not. Being physically away from the office through teleworking may not reduce the effect of maternal harassment on depression. To protect the mental health and employment of pregnant women, employers should comply with the laws and take measures to prevent maternity harassment.

Why public health framing matters: An experimental study of the effects of COVID-19 framing on prejudice and xenophobia in the United States.

The COVID-19 pandemic has triggered a notable increase in the expression of prejudicial and xenophobic attitudes that threaten the wellbeing of minority groups and contribute to the overall public health toll of the virus. However, while there is evidence documenting the growth in discrimination and xenophobia, little is known about how the COVID-19 outbreak is activating the expression of such negative attitudes. The goal of the current paper therefore was to investigate what aspects of the COVID-19 pandemic may be contributing to this rise in expressions of prejudice and xenophobia. More specifically, this study used an experimental design to assess the effects of using stigmatized language to describe the virus as well as the threat to physical health and economic wellbeing posed by the virus on COVID-19 prejudice. Data were collected from a national sample of 1451 adults residing within the United States. Results from 2 × 2 x 2 between-subjects analyses of covariance demonstrated that emphasizing the connection between China and COVID-19, rather than framing the virus neutrally, increased negative attitudes toward Asian Americans, beliefs that resources should be prioritized for Americans rather than immigrants, and general xenophobia. Emphasizing the severity of the economic impact of the virus also increased beliefs that Asian Americans are a threat to resources and general xenophobia. In contrast, messages which emphasized the serious health risks of COVID-19 did not increase bias toward Asian Americans or xenophobia. Our findings suggest that specific types of public health messaging related to infectious diseases, especially framing the virus in terms of its country of origin or its likely economic impact, may elicit prejudice and xenophobia. Public health campaigns that emphasize the severity of the virus, however, are not likely to trigger the same negative attitudes. Implications for public health responses to health crises are discussed.

Factors Associated with Attrition and Performance Throughout Surgical Training: A Systematic Review and Meta-Analysis.

BACKGROUND: Attrition within surgical training is a challenge. In the USA, attrition rates are as high as 20-26%. The factors predicting attrition are not well known. The aim of this systematic review is to identify factors that influence attrition or performance during surgical training. METHOD: The review was performed in line with PRISMA guidelines and registered with the Open Science Framework (OSF). Medline, EMBASE, PubMed and the Cochrane Central Register of Controlled Trials were searched for articles. Risk of bias was assessed using the Newcastle-Ottawa scale. Pooled estimates were calculated using random effects meta-analyses in STATA version 15 (Stata Corp Ltd). A sensitivity analysis was performed including only multi-institutional studies. RESULTS: The searches identified 3486 articles, of which 31 were included, comprising 17,407 residents. Fifteen studies were based on multi-institutional data and 16 on single-institutional data. Twenty-nine of the studies are based on US residents. The pooled estimate for overall attrition was 17% (95% CI 14-20%). Women had a significantly higher pooled attrition than men (24% vs 16%, p < 0.001). Some studies reported Hispanic residents had a higher attrition rate than non-Hispanic residents. There was no increased risk of attrition with age, marital or parental status. Factors reported to affect performance were non-white ethnicity and faculty assessment of clinical performance. Childrearing was not associated with performance. CONCLUSION: Female gender is associated with higher attrition in general surgical residency. Longitudinal studies of contemporary surgical cohorts are needed to investigate the complex multi-factorial reasons for failing to complete surgical residency.

Resident Physician Experiences With and Responses to Biased Patients.

Importance: Biased patient behavior negatively impacts resident well-being. Data on the prevalence and frequency of these encounters are lacking and are needed to guide the creation of institutional trainings and policies to support trainees. Objective: To evaluate the frequency of resident experiences with and responses to a range of biased patient behaviors. Design, Setting, and Participants: A retrospective survey was sent via email to 331 second- and third-year internal medicine residents from 3 academic medical centers in California and North Carolina. First-year residents were excluded owing to their limited interactions with patients at the time of participant recruitment. Data were collected from August 21 to November 25, 2019. Main Outcomes and Measures: Descriptive statistics were used to report the frequency of experience of various types of biased patient behavior, residents' responses, the factors impeding residents' responses, and residents' experiences and beliefs regarding training and policies. Results: Overall, 232 of 331 residents (70%) participated; 116 (50%) were women; 116 of 247 (47%) were White (participants had the option of selecting >1 race/ethnicity); and 23 (10%) identified as lesbian, gay, bisexual, transgender, or queer. The frequency of resident-reported experience of types of biased patient behaviors varied. The most common behaviors-belittling comments and assumption of nonphysician status-were reported to be experienced 1 or more times per week by 14% of residents (32 of 231) and 17% of residents (38 of 230), respectively. Women, Black or Latinx, and Asian residents reported experiencing biased behavior more frequently. Forty-five percent of Black or Latinx residents (17 of 38) encountered instances of explicit epithets or rejection of care. All 70 Asian residents reported experiencing inquiries into their ethnic origins. Most women residents (110 of 115 [96%]) experienced role questioning behaviors, and 87% (100 of 115) experienced sexual harassment. The need to prioritize clinical care and a sense of futility in responding were the most common factors (cited by 34% of residents [76 of 227] and 25% of residents [56 of 227], respectively) significantly impeding responses to biased behaviors. Eighty-five percent of residents (191 of 226) never reported incidents to their institution. Eighty-nine percent of residents (206 of 232) identified training and policies as necessary or very necessary. Conclusions and Relevance: This survey study suggests that biased patient behavior is experienced frequently by internal medicine residents. Non-White and women residents reported experiencing a disproportionate burden of these incidents. Residents' responses rarely included institutional involvement. Residency programs and health care systems should prioritize training and policies to address biased patient behavior and support affected residents.

Experiences of discrimination and self-reported health in Chinese migrants: a structural equation model.

BACKGROUND: Many migrants suffer from discrimination and poor health in China. We sought to examine the associations between experiences of discrimination and self-reported health among internal migrants in China, as well as the mediators of social integration and perceived stress. METHODS: The data was obtained from a specific survey of migrants, as a part of the National Health and Family Planning Dynamic Monitoring for Migrants conducted in 2014. A total of 15,999 migrants aged 15 to 59 years were recruited by a stratified, multistage clustered sampling procedure in eight Chinese cities. Structural Equation Modeling (SEM) was conducted. RESULTS: The results indicated that experiences of discrimination were associated with worse self-reported health (ß = - 0.32, P < 0.001), less social integration (ß = - 0.25, P < 0.001), as well as higher perceived stress (ß = 0.21, P < 0.01). Both objectively measured socioeconomic status (ß = 0.21, P < 0.001) and subjective social status (ß = 0.21, P < 0.01) had significantly positive correlations with self-reported health. CONCLUSIONS: The discrimination, social exclusion and perceived stress experienced by migrants have significant implications on their health.