Unhealthy closets, discriminatory dwellings: The mental health benefits and costs of being open about one's sexual minority status.

RATIONALE: With a concealable stigmatized identity, sexual minorities not only face discrimination but the burden of deciding when to be open about their sexuality. What are the mental health costs and benefits to openness about sexual minority status? On the one hand, openness fosters integration within the LGBTQ + community (yielding downstream benefits), but it also heightens perceptions of discrimination towards oneself and the group at large (yielding downstream costs for mental health). OBJECTIVE: Previous research has focused on openness as reflecting either a cost or a benefit to sexual minorities' mental health, resulting in apparent conflict. We propose an integrated view of openness as leading to both costs and benefits that work in tandem to steer mental health. METHODS: In two pre-registered studies with nearly 4000 ethnically diverse, sexual minority participants, we propose a theoretically-driven serial mediation model to test opposing mediating mechanisms that operate on subjective wellbeing and mental health. Specifically, we determine how the relationship between openness about sexual minority status fosters LGBTQ + identity importance, community integration, and perception of discrimination. RESULTS: Being more (vs. less) open strengthens LGBTQ identity importance, facilitating integration in the LGBTQ + community, which benefits mental health. However, openness and strengthened identity importance simultaneously prompt increased perceptions of discrimination, the burden of which adversely affects mental health. Together these opposing forces explain the weak association between greater openness and mental health - an association that indicates, overall, that openness does have a net benefit for LGBTQ + individuals' mental health. CONCLUSIONS: By identifying opposing mechanisms that underlie the relationship between openness and mental health, we have provided a more integrated perspective on the role that openness plays on sexual minorities' mental health. Openness is associated with stronger group identity importance, greater community integration, and heightened perception that the group (and self) face discrimination.

The Palliative Effects of System Justification on the Health and Happiness of Lesbian, Gay, Bisexual, and Transgender Individuals.

Across three studies, we examine the correlates of subjective well-being and mental and physical health among members of a historically disadvantaged group, namely, lesbian, gay, bisexual, and transgender (LGBT) individuals. Results show those who minimize (vs. acknowledge) the extent to which their group is the target of discrimination report better well-being across myriad indicators (Studies 1-3). We also demonstrate that this effect is mediated by perceived system fairness (Study 1); holds above and beyond internalized homonegativity (Studies 1 and 3) and ingroup identification (Studies 2-3); and is true regardless of whether individuals reside in hostile or accepting environments (Study 2), and regardless of whether individuals had personally experienced discrimination (Study 3). For some indicators (namely, body mass index [BMI], social well-being, self-esteem, depression, and mental illness diagnosis), the relationship between minimization of discrimination and well-being was stronger among those who had frequent (vs. rare) discriminatory experiences.

Improving Communication With Surrogate Decision-Makers: A Pilot Initiative.

BACKGROUND: Difficult conversations in medical care often occur between physicians and patients' surrogates, individuals entrusted with medical decisions for patients who lack the capacity to make them. Poor communication between patients' surrogates and physicians may exacerbate anxiety and guilt for surrogates, and may contribute to physician stress and burnout. OBJECTIVE: This pilot study assesses the effectiveness of an experiential learning workshop that was conducted in a clinical setting, and aimed at improving resident physician communication skills with a focus on surrogate decision-making. METHODS: From April through June 2016, we assessed internal medicine residents' baseline communication skills through an objective structured clinical examination (OSCE) with actors representing standardized surrogates. After an intensive, 6-hour communication skills workshop, residents were reassessed via an OSCE on the same day. A faculty facilitator and the surrogate evaluated participants' communication skills via the expanded Gap Kalamazoo Consensus Statement Assessment Form. Wilcoxon signed rank tests (α of .05) compared mean pre- and postworkshop scores. RESULTS: Of 44 residents, 33 (75%) participated. Participants' average preworkshop OSCE scores (M = 3.3, SD = 0.9) were significantly lower than postworkshop scores (M = 4.3; SD = 0.8; Z = 4.193; P < .001; effect size r = 0.52). After the workshop, the majority of participants self-reported feeling "more confident." CONCLUSIONS: Residents' communication skills specific to surrogate decision-making benefit from focused interventions. Our pilot assessment of a workshop showed promise, and additionally demonstrated the feasibility of bringing OSCEs and simulated encounters into a busy clinical practice.

Stigmatization of substance use disorders among internal medicine residents.

BACKGROUND: Evidence suggests that some physicians harbor negative attitudes towards patients with substance use disorders (SUDs). The study sought to (1) measure internal medicine residents' attitudes towards patients with SUDs and other conditions; (2) determine whether demographic factors influence regard for patients with SUDs; and (3) assess the efficacy of a 10-hour addiction medicine course for improving attitudes among a subset of residents. METHODS: A prospective cohort study of 128 internal medicine residents at an academic medical center in New York City. Scores from the validated Medical Condition Regard Scale (MCRS) were used to assess attitude towards patients with alcoholism, dependence on narcotic pain medication, heartburn, and pneumonia. Demographic variables included gender, postgraduate training year, and prior addiction education. RESULTS: Mean baseline MCRS scores were lower (less regard) for patients with alcoholism (41.4) and dependence on narcotic pain medication (35.3) than for patients with pneumonia (54.5) and heartburn (48.9) (P < .0001). Scores did not differ based upon gender, prior hours of addiction education, or year of training. After the course, MCRS scores marginally increased for patients with alcoholism (mean increased by 0.16, P = .04 [95% confidence interval, CI: 0.004-0.324]) and dependence on narcotic pain medication (mean increased by 0.09, P = .10 [95% CI: 0.02-0.22]). CONCLUSIONS: Internal medicine residents demonstrate less regard for patients with SUDs. Participation in a course in addiction medicine was associated with modest attitude improvement; however, other efforts may be necessary to ensure that patients with potentially stigmatized conditions receive optimal care.

Surrogate expectations in severe brain injury.

OBJECTIVE: To understand what influences surrogate decision-makers' expectation that a patient with a disorder of consciousness (DOC; those in a coma, the vegetative state or the minimally conscious state) will recover. SUBJECTS: Forty-one surrogates representing 37 DOC patients completed a survey about their experiences in having a family member with a DOC. METHODS: A quantitative questionnaire assessed surrogate and patient's demographic, medical and psychosocial features that may explain surrogate's expectation of patient recovery. RESULTS: Surrogates who were more relationally enmeshed with the patient thought the patient could communicate better and thought technology would improve treatment of patients with brain injury had greater expectations of recovery. Source of injury and patient's current diagnosis did not explain expectations. CONCLUSION: Relational factors between the patient and the surrogate may explain the surrogate's expectation that the patient will recover more than factors that matter to clinicians such as the source of injury or the patient's diagnosis.

Lip-reading and the ventilated patient.

OBJECTIVE: To present a clinical ethics case report that illustrates the benefits of using lip-reading interpreters for ventilated patients who are capable of mouthing words. DESIGN: Case report. SETTING: The burn unit of a university teaching hospital in New York City. PATIENT: A 75-yr-old man was admitted to the burn unit with 50% total body surface area burns. He was awake, alert, ventilator-dependent via a tracheostomy, and able to mouth words. INTERVENTIONS: A deaf lip-reading interpreter and a hearing American sign language interpreter worked together in a circuit formation to provide verbal voice for the patient. CONCLUSION: For the ventilated patient who can mouth words, lip-reading interpretation offers an opportunity for communication. It is time we routinely provide lip-reading interpreters as well as recognize the need for prospective studies examining the role of lip-reading in medical settings.

Not so fast: the (not-quite-complete) dissociation between accuracy and confidence in thin-slice impressions.

After decades of research highlighting the fallibility of first impressions, recent years have featured reports of valid impressions based on surprisingly limited information, such as photos and short videos.Yet beneath mean levels of accuracy lies tremendous variance-some snap judgments are well-founded, others wrongheaded. An essential question for perceivers, therefore, is whether and when to trust their initial intuitions about others. In three studies of first impressions based on photos and videos, the authors examined accuracy for Big Five trait judgments as well as corresponding reports of confidence. Overall, perceivers showed a limited ability to intuit which of their impressions were more accurate than others, although a curvilinear effect emerged: In the relatively few cases where perceivers reported an absolute lack of confidence, their accuracy was indeed comparatively low. Across the studies, judgment confidence was shaped by sources at the judgment level and the judge level that were unrelated to accuracy.