Breast Surgery in Adolescents: Cisgender Breast Reduction Versus Transgender and Nonbinary Chest Masculinization.

PURPOSE: Both breast reduction surgery (BRS) in adolescent girls and chest masculinization surgery (CMS) transgender and nonbinary (TGNB) individuals improve physical discomfort and psychological well-being. Nonetheless, CMS in adolescents is highly contested due to concerns regarding safety and capacity for consent. Here, we compare both procedures to quantify trends in incidence, minimum age, and surgical outcomes. METHODS: The National Surgical Quality Improvement Program database was queried from 2018 to 2021 for cisgender and TGNB adolescents 18 years or younger who underwent BRS or CMS. Our primary outcome was the incidence of postoperative complications within 30 days of surgery. Multivariate logistic regression was performed to determine if CMS was associated with postoperative complications. RESULTS: Of 2504 adolescents, the majority (n = 2186 [87.3%]) were cisgender female patients who underwent BRS, compared with TGNB adolescents (n = 318 [12.7%]) who underwent CMS. BRS patients were younger at time of surgery (mean [SD] 16.7 [1.2], 17.5 [0.9]; P < 0.001). The minimum age for BRS was consistently 2 to 3 years younger than that for CMS (12.1 to 12.6 years vs 14.0 to 15.1 years). A comparable frequency of BRS and CMS patients developed 1 or more complications within 30 days of surgery (n = 98 [4.5%], n = 13 [4.1%]; P = 0.775). CONCLUSION: Cisgender female adolescents undergo breast surgery at a 7-fold rate compared with TGNB adolescents and do so at significantly younger ages. Given the favorable effects of BRS and CMS on psychosocial well-being and their comparable surgical risk of complications, our data help recontextualize the concerns surrounding adolescent CMS.

Physicians' Refusal to Wear Masks to Protect Vulnerable Patients-An Ethical Dilemma for the Medical Profession.

This Viewpoint discusses why clinician masking is still important for patients who are immunocompromised or disabled.

How Can Jewish and Non-Jewish People Collaborate to Improve Healthcare in the US? Considering Community, Autonomy, and Solidarity.

The coronavirus 2019 (COVID) pandemic has highlighted the ways in which municipal, state, and Federal agencies in the USA have failed to address the inequities of present-day health systems. As alternative organizing centers outside these agencies, local communities are potentially situated to redress the inequities of present-day health systems in a collaborative manner that demonstrates solidarity by supplementing a purely scientific model of medicine and healthcare. In the mid-twentieth century, the Black Panthers, a revolutionary African American nationalist organization that focused on socialism and self-defense, introduced highly influential free clinics, which sought to bring expertise to the Black community on their own terms. This required bringing the benefits of biomedicine to those who customarily had not seen them. By extension, their approach raises questions regarding community- and expertise-centered approaches for the Jewish community: how is it engaged in healthcare for itself (in its diverse subcategories) and for others? Moreover, understanding how the Jewish community has been ill-served by present-day health-care systems might spur Jewish institutions to reimagine how healthcare should work.

Utilization of a primary care-based cancer survivorship clinic: patterns and patient characteristics.

PURPOSE: The Johns Hopkins Primary Care for Cancer Survivors (PCCS) Clinic was established in 2015 to improve care delivery for the growing cancer survivor population. We aim to describe areas of care addressed by PCCS and factors associated with clinic utilization. METHODS: We conducted a retrospective chart review of the first 301 patients' clinic visits. We used negative binomial regression models to identify factors associated with the rate of PCCS clinic visits overall and for cancer surveillance and treatment-related effects. RESULTS: There were 1702 clinic visits across 301 patients during the study period (77% female, median age 61). The most common areas of care addressed were chronic medical problems (80%), preventive health care (62%), cancer surveillance (59%), treatment-related effects (50%), and new/acute problems (46%). Multivariate analyses found that age > 60 years (IRR = 1.9, 95% CI = 1.2-3.0, p = 0.007) and higher number of comorbidities (IRR = 1.2, 95% CI = 1.1 - 1.2, p < 0.001) were associated with more overall PCCS visits, while female gender was associated with fewer visits (IRR = 0.6, CI = 0.4 - 0.8, p = 0.001). Gastrointestinal cancer type, shorter length of survivorship, male gender, and higher number of comorbidities were associated with a higher rate of visits addressing both surveillance and treatment-related effects (p < 0.05). CONCLUSIONS: The PCCS clinic addressed cancer and non-cancer related needs. Older patients and survivors with more comorbidities had significantly increased clinic utilization. IMPLICATIONS FOR CANCER SURVIVORS: As the cancer survivor population grows, increasing access to survivorship clinics based in primary care may help meet these patients' diverse oncologic and general health needs.

Language and Health (In)Equity in US Latinx Communities.

Language is a social determinant of health, no less so in the case of Latinx persons, who make up the second largest ethnic group in the United States. In US health care, language and linguistic difference are often conceived in discrete, instrumental, and monolithic terms. This article characterizes this conception of language as administrative logic, which is in sharp contrast to language conceived as a richly complex, heterogeneous, communally lived human experience. This article emphasizes the importance of system-level language awareness and epistemic humility for promoting equity, as well as the need to avoid too-narrow focus on linguistic assessment.

El idioma es un determinante social de la salud, tema no menor en el caso de las personas latinx, que constituyen el segundo grupo étnico más grande en los Estados Unidos. En la atención médica de los EE. UU., las diferencias idiomáticas y lingüísticas normalmente se conciben en términos separados, instrumentales y monolíticos. Este artículo caracteriza esta concepción del idioma como lógica administrativa, que contrasta significativamente con la del idioma concebido como un aspecto marcadamente complejo, heterogéneo y comunal de las vivencias humanas. Este artículo enfatiza la importancia de una conciencia idiomática y humildad epistémica a nivel sistémico para promover la equidad, así como la necesidad de evitar un foco demasiado estrecho en la evaluación lingüística.

Primary Care Practice Transformation in the Era of COVID-19 and Beyond: Key Principles for General Internal Medicine Practitioners.

As members of the Clinical Practice Committee (CPC) of the Society for General Internal Medicine (SGIM), we support practice innovation and transformation to achieve a more just system by which all people can achieve and maintain optimal health. The COVID-19 pandemic has tested the US healthcare delivery system and sharpened our national awareness of long-standing and ingrained system shortcomings. In the face of crisis, SGIM members innovated and energetically mobilized to focus on the immediate needs of our patients and communities. Reflecting on these experiences, we are called to consider what was learned from the pandemic that applies to the future of healthcare delivery. CPC members include leaders in primary care delivery, practice finance, quality of care, patient safety, hospital practice, and health policy. CPC members provide expertise in clinical practice, serving as primary care doctors, hospitalists, and patient advocates who understand the intensity of care needed for those with severe COVID-19 infections, the disproportionate impact of the pandemic on Black and Brown communities, the struggles created for those with poor access to care, and the physical and emotional impact it has placed on patients, families, and clinicians. In this consensus statement, we summarize lessons learned from the 2020-2021 pandemic and their broader implications for reform in healthcare delivery. We provide a platform for future work by identifying many interactive elements of healthcare delivery that must be simultaneously addressed in order to ensure that care is accessible, equitably provided, patient-centered, and cost-effective.

The submissive silence of others: Examining definitions of shared decision making.

OBJECTIVE: Our aim was to use critical discourse analysis (CDA) to examine the most widely cited definitions of shared decision making so that we can evaluate how language is used to position participants. Based on our conceptual understanding, we presumed that shared decision making involves acts of communication where processes are collaborative. METHODS: We used a CDA lens to closely examine the phrases, semantics, syntax, implied functions, and the social actions proposed in SDM definition texts. We conducted a systematic search guided by the PRISMA guidelines, to identify the most widely cited definitions of SDM. RESULTS: A total of 72 studies met our inclusion criteria. While SDM is not consistently defined, it was striking to find that clinicians are constructed as active whereas patients were viewed to be passive participants. The definitions construct SDM to be a gift that the clinician has the power to offer, and the relationship in the definitions appears asymmetric, in which only one party seems to speak. CONCLUSIONS: The SDM definitions examined convey a process characterized by a clinician who speaks, while a patient mostly listens, and is invited to contribute. An alternative definition might be constructed through references to joint activity via sentences in active voice. PRACTICE IMPLICATIONS: Clinicians may be influenced by definitions of SDM that reinforce the positionality of active speaker versus passive recipient. Clearer definitions that address the constructs of power and roles may help support the implementation of SDM.

COVID-19 Vaccine Uptake Through the Lived Experiences of Health Care Personnel: Policy and Legal Considerations.

Purpose: To investigate whether coronavirus disease 2019 (COVID-19) vaccination campaigns targeted at health care personnel (HCP) in the United States have addressed the lived experiences of HCP on the frontlines of the COVID-19 pandemic and to analyze policy and legal considerations for improving COVID-19 vaccine uptake among HCP. Methods: We conducted a literature and policy review to explore the lived experiences of different occupational groups of HCP on the frontlines of the COVID-19 pandemic-physicians, nurses, trainees, and nonclinical essential workers-in relation to ongoing COVID-19 vaccination campaigns. Finally, we discuss policy and legal considerations to improve the state of HCP COVID-19 vaccine uptake as the pandemic progresses. Results: COVID-19 vaccination campaigns have not achieved consistent high uptake among HCP for many reasons, including vaccine hesitancy, personal, professional considerations, and equity-rooted challenges. Conclusion: HCPs lived experiences during the COVID-19 pandemic reveal meaningful impediments to their COVID-19 vaccine uptake. We suggest that health care systems minimize inequity inherent in existing vaccination campaigns by providing financial and social support to HCP to raise HCP COVID-19 vaccine uptake.

Can You Hear Me Now? Effects of Patient-Centered Communication With Young Adults Aged 26 to 39.

Patient-centered communication (PCC) is critical to the delivery of quality health care services. Although numerous health outcomes have been connected to patient-provider communication, there is limited research that has explored the processes and pathways between communication and health. Research among young adults (ages 26-39 years) is even more scarce, despite findings that health communication does vary with age. This cross-sectional study used data from the 2014 Health Interview National Trends Survey to explore the relationship between PCC, patient trust, patient satisfaction, social support, self-care skills, and emotional well-being among young adults aged 26 to 39 years. Our results showed that income, history of depression diagnosis, PCC, patient trust, social support, and patient self-efficacy (self-care skills) were all significantly related to emotional well-being. These findings suggest the need to explore the means through which communication can impact emotional well-being, specifically among young adults who are in poor health or have a history of depression. Future research should also include longitudinal studies, in order to determine causality and directionality among constructs.

Healthcare Professionals' Experience, Training, and Knowledge Regarding Immigration-Related Law Enforcement in Healthcare Facilities: An Online Survey.

U.S. immigration policies and enforcement can make immigrants fearful of accessing healthcare. Although current immigration policies restrict enforcement in "sensitive locations" including healthcare facilities, there are reports of enforcement actions in such settings.

Care for Incarcerated Patients Hospitalized with COVID-19.

The COVID-19 pandemic has reshaped health care delivery for all patients but has distinctly affected the most marginalized people in society. Incarcerated patients are both more likely to be infected and more likely to die from COVID-19. There is a paucity of guidance for the care of incarcerated patients hospitalized with COVID-19. This article will discuss how patient privacy, adequate communication, and advance care planning are rights that incarcerated patients may not experience during this pandemic. We highlight the role of compassionate release and note how COVID-19 may affect this prospect. A number of pragmatic recommendations are made to attenuate the discrepancy in hospital care experienced by those admitted from prisons and jails. Physicians must be familiar with the relevant hospital policies, be prepared to adapt their practices in order to overcome barriers to care, such as continuous shackling, and advocate to change these policies when they conflict with patient care. Stigma, isolation, and concerns over staff safety are shared experiences for COVID-19 and incarcerated patients, but incarcerated patients have been experiencing this treatment long before the current pandemic. It is crucial that the internist demand the equitable care that we seek for all our patients.

The Treatment of Disability under Crisis Standards of Care: An Empirical and Normative Analysis of Change over Time during COVID-19.

CONTEXT: COVID-19 has prompted debates between bioethicists and disability activists about Crisis Standards of Care plans (CSCs), triage protocols determining the allocation of scarce lifesaving care. METHODS: We examine CSCs in 35 states and code how they approach disability, comparing states that have revised their plans over time to those that have not. We offer ethical and legal analyses evaluating to what extent changes to state policy aligned with disability rights law and ethics during the early pandemic and subsequently as stakeholder engagement grew. FINDINGS: While disability rights views were not well represented in CSCs that were not updated or updated early in the pandemic, states that revised their plans later in the pandemic were more aligned with advocate priorities. However, many CSCs continue to include concerning provisions, especially the reliance on long-term survival, which implicates considerations of both disability rights and racial justice. CONCLUSIONS: The disability rights movement's successes in influencing state triage policy should inform future CSCs and set the stage for further work on how stakeholders influence bioethics policy debates. We offer thoughts for examining bioethics policy making reflecting the processes by which activists seek policy change and the tension policy makers face between expert delegation and mediating values conflicts.

Long COVID and Health Inequities: The Role of Primary Care.

Policy Points An estimated 700,000 people in the United States have "long COVID," that is, symptoms of COVID-19 persisting beyond three weeks. COVID-19 and its long-term sequelae are strongly influenced by social determinants such as poverty and by structural inequalities such as racism and discrimination. Primary care providers are in a unique position to provide and coordinate care for vulnerable patients with long COVID. Policy measures should include strengthening primary care, optimizing data quality, and addressing the multiple nested domains of inequity.

Informing the Design of a New Pragmatic Registry to Stimulate Near Miss Reporting in Ambulatory Care.

OBJECTIVE: Ambulatory care safety is of emerging concern, especially in light of recent studies related to diagnostic errors and health information technology-related safety. Safety reporting systems in outpatient care must address the top safety concerns and be practical and simple to use. A registry that can identify common near misses in ambulatory care can be useful to facilitate safety improvements. We reviewed the literature on medical errors in the ambulatory setting to inform the design of a registry for collecting near miss incidents. METHODS: This narrative review included articles from PubMed that were: 1) original research; 2) discussed near misses or adverse events in the ambulatory setting; 3) relevant to US health care; and 4) published between 2002 and 2013. After full text review, 38 studies were searched for information on near misses and associated factors. Additionally, we used expert opinion and current inpatient near miss registries to inform registry development. RESULTS: Studies included a variety of safety issues including diagnostic errors, treatment or management-related errors, communication errors, environmental/structural hazards, and health information technology (health IT)-related concerns. The registry, based on the results of the review, updates previous work by including specific sections for errors associated with diagnosis, communication, and environment structure and incorporates specific questions about the role of health information technology. CONCLUSIONS: Through use of this registry or future registries that incorporate newly identified categories, near misses in the ambulatory setting can be accurately captured, and that information can be used to improve patient safety.