What Do Placebo and Nocebo Effects Have to Do With Health Equity? The Hidden Toll of Nocebo Effects on Racial and Ethnic Minority Patients in Clinical Care.

A placebo effect is a positive clinical response to non-specific elements of treatment with a sham or inert replica of a drug, device, or surgical intervention. There is considerable evidence that placebo effects are driven by expectation of benefit from the intervention. Expectation is shaped by a patient's past experience, observations of the experience of others, and written, verbal, or non-verbal information communicated during treatment. Not surprisingly, expectation in the clinical setting is strongly influenced by the attitude, affect, and communication style of the healthcare provider. While positive expectations can produce beneficial effects, negative information and experiences can lead to negative expectations, and consequently negative or nocebo effects. Key components identified and studied in the placebo and nocebo literature intersect with factors identified as barriers to quality care in the clinical setting for Black patients and other patients of color, including poor patient-clinician communication, medical mistrust, and perceived discrimination. Thus, in the context of discrimination and bias, the absence of placebo and presence of nocebo-generating influences in clinical settings could potentially reinforce racial and ethnic inequities in clinical outcomes and care. Healthcare inequities have consequences that ripple through the medical system, strengthening adverse short- and long-term outcomes. Here, we examine the potential for the presence of nocebo effects and absence of placebo effects to play a role in contributing to negative outcomes related to unequal treatment in the clinical encounter.

How Do Presenting Symptoms and Outcomes Differ by Race/Ethnicity Among Hospitalized Patients With Coronavirus Disease 2019 Infection? Experience in Massachusetts.

BACKGROUND: Population-based literature suggests severe acute respiratory syndrome coronavirus 2 infection may disproportionately affect racial/ethnic minorities; however, patient-level observations of hospitalization outcomes by race/ethnicity are limited. Our aim in this study was to characterize coronavirus disease 2019 (COVID-19)-associated morbidity and in-hospital mortality by race/ethnicity. METHODS: This was a retrospective analysis of 9 Massachusetts hospitals including all consecutive adult patients hospitalized with laboratory-confirmed COVID-19. Measured outcomes were assessed and compared by patient-reported race/ethnicity, classified as white, black, Latinx, Asian, or other. Student t test, Fischer exact test, and multivariable regression analyses were performed. RESULTS: A total of 379 patients (aged 62.9 ± 16.5 years; 55.7% men) with confirmed COVID-19 were included (49.9% white, 13.7% black, 29.8% Latinx, 3.7% Asian), of which 376 (99.2%) were insured (34.3% private, 41.2% public, 23.8% public with supplement). Latinx patients were younger, had fewer cardiopulmonary disorders, were more likely to be obese, more frequently reported fever and myalgia, and had lower D-dimer levels compared with white patients (P < .05). On multivariable analysis controlling for age, gender, obesity, cardiopulmonary comorbidities, hypertension, and diabetes, no significant differences in in-hospital mortality, intensive care unit admission, or mechanical ventilation by race/ethnicity were found. Diabetes was a significant predictor for mechanical ventilation (odds ratio [OR], 1.89; 95% confidence interval [CI], 1.11-3.23), while older age was a predictor of in-hospital mortality (OR, 4.18; 95% CI, 1.94-9.04). CONCLUSIONS: In this multicenter cohort of hospitalized COVID-19 patients in the largest health system in Massachusetts, there was no association between race/ethnicity and clinically relevant hospitalization outcomes, including in-hospital mortality, after controlling for key demographic/clinical characteristics. These findings serve to refute suggestions that certain races/ethnicities may be biologically predisposed to poorer COVID-19 outcomes.

Rallying Against Racism: Hospitals Join the Fight for Racial Justice.

This article highlights the timely situation that resident physicians, faculty, and staff are facing after the recent highly publicized murders of Black Americans and its impact on our healthcare communities. We discuss our experiences of how the hospital can serve as a meeting place for anti-racism, as well as how anti-racist events at the hospital can raise public consciousness and be catalysts for creating a more inclusive, diverse, and welcoming environment for all members of hospital communities.

Promoting Success: A Professional Development Coaching Program for Interns in Medicine.

BACKGROUND: Residency is an intense period. Challenges, including burnout, arise as new physicians develop their professional identities. Residency programs provide remediation, but emotional support for interns is often limited. Professional development coaching of interns, regardless of their performance, has not been reported. OBJECTIVE: Design, implement, and evaluate a program to support intern professional development through positive psychology coaching. METHODS: We implemented a professional development coaching program in a large residency program. The program included curriculum development, coach-intern interactions, and evaluative metrics. A total of 72 internal medicine interns and 26 internal medicine faculty participated in the first year. Interns and coaches were expected to meet quarterly; expected time commitments per year were 9 hours (per individual coached) for coaches, 5 1/2 hours for each individual coachee, and 70 hours for the director of the coaching program. Coaches and interns were asked to complete 2 surveys in the first year and to participate in qualitative interviews. RESULTS: Eighty-two percent of interns met with their coaches 3 or more times. Coaches and their interns assessed the program in multiple dimensions (participation, program and professional activities, burnout, coping, and coach-intern communication). Most of the interns (94%) rated the coaching program as good or excellent, and 96% would recommend this program to other residency programs. The experience of burnout was lower in this cohort compared with a prior cohort. CONCLUSIONS: There is early evidence that a coaching program of interactions with faculty trained in positive psychology may advance intern development and partially address burnout.

Implementing a pilot leadership course for internal medicine residents: design considerations, participant impressions, and lessons learned.

BACKGROUND: Effective clinical leadership is associated with better patient care. We implemented and evaluated a pilot clinical leadership course for second year internal medicine residents at a large United States Academic Medical Center that is part of a multi-hospital health system. METHODS: The course met weekly for two to three hours during July, 2013. Sessions included large group discussions and small group reflection meetings. Topics included leadership styles, emotional intelligence, and leading clinical teams. Course materials were designed internally and featured "business school style" case studies about everyday clinical medicine which explore how leadership skills impact care delivery. Participants evaluated the course's impact and quality using a post-course survey. Questions were structured in five point likert scale and free text format. Likert scale responses were converted to a 1-5 scale (1 = strongly disagree; 3 = neither agree nor disagree; 5 = strongly agree), and means were compared to the value 3 using one-way T-tests. Responses to free text questions were analyzed using the constant comparative method. RESULTS: All sixteen pilot course participants completed the survey. Participants overwhelmingly agreed that the course provided content and skills relevant to their clinical responsibilities and leadership roles. Most participants also acknowledged that taking the course improved their understanding of their strengths and weaknesses as leaders, different leadership styles, and how to manage interpersonal conflict on clinical teams. 88% also reported that the course increased their interest in pursuing additional leadership training. CONCLUSIONS: A clinical leadership course for internal medicine residents designed by colleagues, and utilizing case studies about clinical medicine, resulted in significant self-reported improvements in clinical leadership competencies.

Perspectives on HIV prevention among urban black women: a potential role for HIV pre-exposure prophylaxis.

Limited data exist regarding attitudes and acceptability of topical and oral HIV pre-exposure prophylaxis (PrEP) among US black women. This investigation explored interest in HIV chemoprophylaxis and modes of use. Five focus groups enrolled 26 black women recruited from an inner-city community health center and affiliated HIV testing sites. Thematic analysis utilized Atlas.ti. Most women expressed interest in PrEP, as many reported condom failure concerns. Most women preferred a pill formulation to intravaginal gel because of greater perceived privacy and concerns about vaginal side effects and gel leakage. Women who had taken pills previously advocated daily dosing and indicated adherence concerns about episodic or post-coital PrEP. Many women desired prophylactic strategies that included partner testing. Urban black women are interested in utilizing PrEP; however, misgivings exist about gel inconvenience and potential side effects for themselves and their partners. Most women preferred oral PrEP, dosed daily.

Influence of providers and nurses on completion of non-targeted HIV screening in an urgent care setting.

INTRODUCTION: Despite recommendations by the Centers for Disease Control (CDC) that all adults be offered non-targeted HIV screening in all care settings, screening in acute-care settings remains unacceptably low. We performed an observational study to evaluate an HIV screening pilot in an academic-community partnership health center urgent care clinic. METHODS: We collected visit data via encounter forms and demographic and laboratory data from electronic medical records. A post-pilot survey of perceptions of HIV screening was administered to providers and nurses. Multivariable analysis was used to identify factors associated with completion of testing. RESULTS: Visit provider and triage nurse were highly associated with both acceptance of screening and completion of testing, as were younger age, male gender, and race/ethnicity. 23.5% of patients completed tests, although 36.0% requested screening; time constraints as well as risk perceptions by both the provider and patient were cited as limiting completion of screening. Post-pilot surveys showed mixed support for ongoing HIV screening in this setting by providers and little support by nurses. CONCLUSIONS: Visit provider and triage nurse were strongly associated with acceptance of testing, which may reflect variable opinions of HIV screening in this setting by clinical staff. Among patients accepting screening, visit provider remained strongly associated with completion of testing. Despite longstanding recommendations for non-targeted HIV screening, further changes to improve the testing and results process, as well as provider education and buy-in, are needed to improve screening rates.

Ambulatory training for primary care general internists: innovation with the affordable care act in mind.

BACKGROUND: Although primary care general internists (PCGIs) are essential to the physician workforce and the success of the Affordable Care Act, they are becoming an endangered species. OBJECTIVE: We describe an expanded program to educate PCGIs to meet the needs of a reformed health care system and detail the competencies PCGIs will need for their roles in team-based care. INTERVENTION: We recommended 5 initiatives to stabilize and expand the PCGI workforce: (1) caring for a defined patient population, (2) leading and serving as members of multidisciplinary health care teams, (3) participating in a medical neighborhood, (4) improving capacity for serving complex patients in group practices and accountable care organizations, and (5) finding an academic role for PCGIs, including clinical, population health, and health services research. A revamped approach to PCGI education based in teaching health centers formed by community health center and academic medical center partnerships would facilitate these curricular innovations. ANTICIPATED OUTCOMES: New approaches to primary care education would include multispecialty group practices facilitated by electronic consultation and clinical decision-support systems provided by the academic medical center partner. Multiprofessional and multidisciplinary education would prepare PCGI trainees with relevant skills for 21st century practice. The centers would also serve as sites for state and federal Medicaid graduate medical education (GME) expansion funding, making this funding more accountable to national health workforce priorities. CONCLUSIONS: The proposed innovative approach to PCGI training would provide an innovative educational environment, enhance general internist recruitment, provide team-based care for underserved patients, and ensure accountability of GME funds.

HIV/AIDS in Women and Racial/Ethnic Minorities in the U.S.

The clinical issues affecting women with HIV/AIDS differ little from those affecting men. However, current research shows that treatment and outcome disparities affect many women with HIV, hypothesized to result from a complex interplay of socioeconomic and gender role influences. These disparities are also a reflection of racial/ethnic differences in treatment and outcome, since 80% of women with HIV/AIDS are black or Hispanic. Women have unique needs for HIV prevention - both prevention of sexual transmission to or from sexual partners and prevention of perinatal transmission. Racial/ethnic minorities continue to be disproportionately affected by the HIV/AIDS epidemic in the U.S. Minorities are less likely to be in care and on HAART than others with HIV/AIDS. These disparities result in poorer outcomes for minorities, especially blacks, with HIV/AIDS. New strategies for optimizing engagement and retention in care, and for prevention hold great promise for women and minorities with HIV in the U.S.

Social and emotional competence in traumatic brain injury: new and established assessment tools.

Chronic social/emotional deficits are common in moderate to severe traumatic brain injury (TBI), leading to significant functional difficulties. Objective, quantitative tools for assessing social/emotional competence are an important adjunct to cognitive assessments. We review existing social/emotional measures, conclude that theory of mind tests are not adequate for clinical assessments of social competence, and explain the development and piloting of novel measures in a small group of moderate to severe TBI patients (N = 16) and non-brain-damaged controls (N = 16). The novel measures are the Global Interpersonal Skills Test (GIST), a questionnaire measuring informant-rated social skills; the Assessment of Social Context (ASC), a video-based task examining understanding of others' emotions, attitudes, and intentions; the Social Interpretations Test, a social framing task based on Heider and Simmel ( 1944 ); and Awareness of Interoception, a heartbeat-detection paradigm related to physiological self-awareness. In a MANOVA, other-rated social skills (GIST), ASC, and Awareness of Interoception scores were significantly lower for TBI patients than controls. ASC, r(31) = .655, and Social Interpretations, r(31) = .460, scores were significantly correlated with informant-rated social skills (GIST). We encourage clinicians to add social/emotional measures to assessments of TBI patients.

The Social Vulnerability Scale for Older Adults: An Exploratory and Confirmatory Factor Analytic Study.

The Social Vulnerability Scale (SVS), a 22-item informant report of vulnerability to exploitation and, in particular, financial exploitation of older adults, was administered to 266 respondents who assessed the social vulnerability of a significant other aged 50 years or over, either a person with dementia or other neurological condition (n = 116), or a healthy adult (n = 150). Exploratory factor analysis in the combined sample revealed a 15-item two-factor solution labeled gullibility and credulity. Stability in factor structure was established in an independent sample (n = 123) using confirmatory factor analysis, and sound reliability (internal consistency) and validity (known-groups) were demonstrated. The SVS15 is a potentially useful instrument for assessing older adults' vulnerability to exploitation.

Multi-dimensional risk factor patterns associated with non-use of highly active antiretroviral therapy among human immunodeficiency virus-infected women.

OBJECTIVES: Relationships between non-use of highly active antiretroviral therapy (HAART), race/ethnicity, violence, drug use, and other risk factors are investigated using qualitative profiles of five risk factors (unprotected sex, multiple male partners, heavy drinking, crack, cocaine or heroin use, and exposure to physical violence) and association of the profiles and race/ethnicity with non-use of HAART over time. METHODS: A hidden Markov model was used to summarize risk factor profiles and changes in profiles over time in a longitudinal sample of HIV-infected women enrolled in the Women's Interagency HIV Study with follow-up from 2002 to 2005 (n = 802). RESULTS: Four risk factor profiles corresponding to four distinct latent states were identified from the five risk factors. Trajectory analysis indicated that states characterized by high probabilities of all risk factors or by low probabilities of all risk factors were both relatively stable over time. Being in the highest risk state did not significantly elevate the odds of HAART non-use (odds ratio [OR], 1.05; 95% confidence interval [CI], 0.6-1.8). However, being in a latent state characterized by elevated probabilities of heavy drinking and exposure to physical violence, along with slight elevations in three other risk factors, significantly increased odds of HAART non-use (OR, 1.4; 95% CI, 1.1-1.9). CONCLUSION: The research suggests that HAART use might be improved by interventions aimed at women who are heavy drinkers with recent exposure to physical violence and evidence of other risk factors. More research about the relationship between clustering and patterns of risk factors and use of HAART is needed.

Association of race, substance abuse, and health insurance coverage with use of highly active antiretroviral therapy among HIV-infected women, 2005.

OBJECTIVES: We examined racial/ethnic disparities in highly active antiretroviral therapy (HAART) use and whether differences are moderated by substance use or insurance status, using data from the Women's Interagency HIV Study (WIHS). METHODS: Logistic regression examined HAART use in a longitudinal cohort of women for whom HAART was clinically indicated in 2005 (N = 1354). RESULTS: Approximately 3 of every 10 eligible women reported not taking HAART. African American and Hispanic women were less likely than were White women to use HAART. After we adjusted for potential confounders, the higher likelihood of not using HAART persisted for African American but not for Hispanic women. Uninsured and privately insured women, regardless of race/ethnicity, were less likely than were Medicaid enrollees to use HAART. Although alcohol use was related to HAART nonuse, illicit drug use was not. CONCLUSIONS: These findings suggest that expanding and improving insurance coverage should increase access to antiretroviral therapy across racial/ethnic groups, but it is not likely to eliminate the disparity in use of HAART between African American and White women with HIV/AIDS.