Implicit bias instruction across disciplines related to the social determinants of health: a scoping review.

One criticism of published curricula addressing implicit bias is that few achieve skill development in implicit bias recognition and management (IBRM). To inform the development of skills-based curricula addressing IBRM, we conducted a scoping review of the literature inquiring, "What interventions exist focused on IBRM in professions related to social determinants of health: education, law, social work, and the health professions inclusive of nursing, allied health professions, and medicine?"Authors searched eight databases for articles published from 2000 to 2020. Included studies: (1) described interventions related to implicit bias; and (2) addressed knowledge, attitude and/or skills as outcomes. Excluded were interventions solely focused on reducing/neutralizing implicit bias. Article review for inclusion and data charting occurred independently and in duplicate. Investigators compared characteristics across studies; data charting focused on educational and assessment strategies. Fifty-one full-text articles for data charting and synthesis, with more than 6568 learners, were selected. Educational strategies included provocative/engagement triggers, the Implicit Association Test, reflection and discussion, and various active learning strategies. Most assessments were self-report, with fewer objective measures. Eighteen funded studies utilized federal, foundation, institutional, and private sources. This review adds to the literature by providing tangible examples of curricula to complement existing frameworks, and identifying opportunities for further research in innovative skills-based instruction, learner assessment, and development and validation of outcome metrics. Continued research addressing IBRM would enable learners to develop and practice skills to recognize and manage their implicit biases during clinical encounters, thereby advancing the goal of improved, equitable patient outcomes.

Frontline Physician Perspectives on Their Experiences Working During the First Wave of the COVID-19 Pandemic.

BACKGROUND: During the first wave of the COVID-19 pandemic physicians worked on the front lines, immersed in uncertainty. Research into perspectives of frontline physicians has lagged behind clinical innovation throughout the pandemic. OBJECTIVE: To inform ongoing and future efforts in the COVID-19 pandemic, we conducted a qualitative exploration of physician perspectives of the effects of policies and procedures as well as lessons learned while caring for patients during the height of the first wave in the spring of 2020. DESIGN: A confidential survey was emailed to a convenience sample. Survey questions included demographic data, participant role in the pandemic, and geographic location. Eleven open-ended questions explored their perspectives and advice they would give going forward. Broad areas covered included COVID-19-specific education, discharge planning, unintended consequences for patient care, mental health conditions to anticipate, and personal/institutional factors influencing workforce well-being amid the crisis. PARTICIPANTS: We received fifty-five surveys from May through July 2020. Demographic data demonstrated sampling of frontline physicians working in various epicenters in the USA, and diversity in gender, race/ethnicity, and clinical specialty. APPROACH: Inductive thematic analysis. KEY RESULTS: Four themes emerged through data analysis: (1) Leadership can make or break morale; (2) Leadership should engage frontline workers throughout decision-making processes; (3) Novelty of COVID-19 led to unintended consequences in care delivery; and (4) Mental health sequelae will be profound and pervasive. CONCLUSIONS: Our participants demonstrated the benefit of engaging frontline physicians as important stakeholders in policy generation, evaluation, and revision; they highlighted challenges, successes, unintended consequences, and lessons learned from various epicenters in the first wave of the COVID-19 pandemic. There is much to be learned from the early COVID-19 pandemic crisis; our participants' insights elucidate opportunities to examine institutional performance, effect policy change, and improve crisis management in order to better prepare for this and future pandemics.

Qualitative analysis of medical student reflections on the implicit association test.

INTRODUCTION: Health professions educators use the Implicit Association Test (IAT) to raise awareness of implicit bias in learners, often engendering strong emotional reactions. Once an emotional reaction ensues, the gap between learner reaction and strategy identification remains relatively underexplored. To better understand how learners may identify bias mitigation strategies, the authors explored perspectives of medical students during the clinical portion of their training to the experience of taking the IAT, and the resulting feedback. METHODS: Medical students in Bronx, NY, USA, participated in one 90-minute session on implicit bias. The focus of analysis for this study is the post-session narrative assignment inviting them to take the race-based IAT and describe both their reaction to and the implications of their IAT results on their future work as physicians. The authors analysed 180 randomly selected de-identified essays completed from 2013 to 2019 using an approach informed by constructivist grounded theory methodology. RESULTS: Medical students with clinical experience respond to the IAT through a continuum that includes their reactions to the IAT, acceptance of bias along with a struggle for strategy identification, and identification of a range of strategies to mitigate the impact of bias on clinical care. Results from the IAT invoked deep emotional reactions in students, and facilitated a questioning of previous assumptions, leading to paradigm shifts. An unexpected contrast to these deep and meaningful reflections was that students rarely chose to identify a strategy, and those that did provided strategies that were less nuanced. CONCLUSION: Despite accepting implicit bias in themselves and desiring to provide unbiased care, students struggled to identify bias mitigation strategies, a crucial prerequisite to skill development. Educators should endeavour to expand instruction to bridge the chasm between students' acceptance of bias and skill development in management of bias to improve the outcomes of their clinical encounters.

Twelve tips for teaching implicit bias recognition and management.

Implicit biases describe mental associations that affect our actions in an unconscious manner. We can hold certain implicit biases regarding members of certain social groups. Such biases can perpetuate health disparities by widening inequity and decreasing trust in both healthcare and medical education. Despite the widespread discourse about bias in medical education, teaching and learning about the topic should be informed by empirical research and best practice. In this paper, the authors provide a series of twelve tips for teaching implicit bias recognition and management in medical education. Each tip provides a specific and practical strategy that is theoretically and empirically developed through research and evaluation. Ultimately, these twelve tips can assist educators to incorporate implicit bias instruction across the continuum of medical education to improve inequity and advance justice.

Validity evidence for a novel instrument assessing medical student attitudes toward instruction in implicit bias recognition and management.

BACKGROUND: Implicit bias instruction is becoming more prevalent in health professions education, with calls for skills-based curricula moving from awareness and recognition to management of implicit bias. Evidence suggests that health professionals and students learning about implicit bias ("learners") have varying attitudes about instruction in implicit bias, including the concept of implicit bias itself. Assessing learner attitudes could inform curriculum development and enable instructional designs that optimize learner engagement. To date, there are no instruments with evidence for construct validity that assess learner attitudes about implicit bias instruction and its relevance to clinical care. METHODS: The authors developed a novel instrument, the Attitude Towards Implicit Bias Instrument (ATIBI) and gathered evidence for three types of construct validity- content, internal consistency, and relationship to other variables. RESULTS: Authors utilized a modified Delphi technique with an interprofessional team of experts, as well as cognitive interviews with medical students leading to item refinement to improve content validity. Seven cohorts of medical students, N = 1072 completed the ATIBI. Psychometric analysis demonstrated high internal consistency (α = 0.90). Exploratory factor analysis resulted in five factors. Analysis of a subset of 100 medical students demonstrated a moderate correlation with similar instruments, the Integrative Medicine Attitude Questionnaire (r = 0.63, 95% CI: [0.59, 0.66]) and the Internal Motivation to Respond Without Prejudice Scale (r = 0.36, 95% CI: [0.32, 0.40]), providing evidence for convergent validity. Scores on our instrument had low correlation to the External Motivation to Respond Without Prejudice Scale (r = 0.15, 95% CI: [0.09, 0.19]) and the Groningen Reflection Ability Scale (r = 0.12, 95% CI: [0.06, 0.17]) providing evidence for discriminant validity. Analysis resulted in eighteen items in the final instrument; it is easy to administer, both on paper form and online. CONCLUSION: The Attitudes Toward Implicit Bias Instrument is a novel instrument that produces reliable and valid scores and may be used to measure medical student attitudes related to implicit bias recognition and management, including attitudes toward acceptance of bias in oneself, implicit bias instruction, and its relevance to clinical care.

Influence of ripening stage and de-astringency treatment on the production of dehydrated persimmon snacks.

BACKGROUND: Seasonal persimmon (Diospyros kaki L.) crops have steadily increased in Spain; this has been linked to a significant increase in the postharvest production waste. Therefore, development of valorized products is of great interest. In this study, a hot air-drying technique was used to obtain persimmon snacks. Slices from astringent and non-astringent persimmons (submitted to de-astringency treatment) at three different ripening stages were dried at 40 and 60 °C to reach 15 ± 3% water content. RESULTS: After the drying treatment, dehydrated samples were harder, turned into a more orange hue angle, and had a reduced soluble tannin content. Dehydrated samples obtained from the astringent fruit at the most advanced ripening stage had similar soluble tannin content as the samples obtained from non-astringent fruit, especially at 60 °C. Besides, a high correlation was observed between the level of astringency perceived by consumers and the decrease of soluble tannin content. Although, in the first ripening stage, consumers preferred the snacks obtained from non-astringent fruits; in the last ripening stage, snacks produced from astringent fruits were equally accepted than the non-astringent ones. CONCLUSION: Therefore, well-accepted persimmon snacks are obtained from both astringent and non-astringent fruits when advanced ripening stages of persimmon are used. © 2020 Society of Chemical Industry.

A Qualitative Study of New York Medical Student Views on Implicit Bias Instruction: Implications for Curriculum Development.

BACKGROUND: For at least the past two decades, medical educators have worked to improve patient communication and health care delivery to diverse patient populations; despite efforts, patients continue to report prejudice and bias during their clinical encounters. Targeted instruction in implicit bias recognition and management may promote the delivery of equitable care, but students at times resist this instruction. Little guidance exists to overcome this resistance and to engage students in implicit bias instruction; instruction over time could lead to eventual skill development that is necessary to mitigate the influence of implicit bias on clinical practice behaviors. OBJECTIVE: To explore student perceptions of challenges and opportunities when participating in implicit bias instruction. APPROACH: We conducted a qualitative study that involved 11 focus groups with medical students across each of the four class years to explore their perceptions of challenges and opportunities related to participating in such instruction. We analyzed transcripts for themes. KEY RESULTS: Our analysis suggests a range of attitudes toward implicit bias instruction and identifies contextual factors that may influence these attitudes. The themes were (1) resistance; (2) shame; (3) the negative role of the hidden curriculum; and (4) structural barriers to student engagement. Students expressed resistance to implicit bias instruction; some of these attitudes are fueled from concerns of anticipated shame within the learning environment. Participants also indicated that student engagement in implicit bias instruction was influenced by the hidden curriculum and structural barriers. CONCLUSIONS: These insights can inform future curriculum development efforts. Considerations related to instructional design and programmatic decision-making are highlighted. These considerations for implicit bias instruction may provide useful frameworks for educators looking for opportunities to minimize student resistance and maximize engagement in multi-session instruction in implicit bias recognition and management.

Reference intervals for hemoglobin A1c (HbA1c) in healthy Mexican pregnant women: a cross-sectional study.

BACKGROUND: The reference intervals for hemoglobin A1c (HbA1c) in pregnant Mexican women without diabetes are not well defined. The study aims to determine the reference intervals for HbA1c at each trimester in healthy Mexican pregnant women. METHODS: This cross-sectional study included healthy Mexican pregnant women in trimester 1 (T1), 6-13.6 weeks of gestation (WG), trimester 2 (T2), 14-27 WG, and trimester 3 (T3), ≥27-36 WG, with a maternal age > 18 years, and pregestational body mass index (BMI) ranging between 18.5-24.9 kg/m2. Women with gestational diabetes mellitus, pregestational diabetes, anemia, a pregestational BMI < 18.5 or ≥ 25 kg/m2, and any hematologic, hepatic, immunological, renal, or cardiac disease were excluded. HbA1c was measured using high-performance liquid chromatography based on the National Glycohemoglobin Standardization Program-certified PDQ Primus guidelines. The HbA1c reference intervals were calculated in terms of the 2.5th to the 97.5th percentiles. RESULTS: We analyzed the HbA1c values of 725 women (T1 n = 84, T2 n = 448, and T3 n = 193). The characteristics of the participants were expressed as mean ± standard deviation and included: maternal age (28.2 ± 6.7 years), pregestational weight (54.8 ± 5.9 Kg), pregestational BMI (22.2 ± 1.7 Kg/m2), and glucose values using a 75 g-2 h oral glucose tolerance test; fasting 4.5 ± 0.3 mmol/L (81.5 ± 5.5 mg/dL), 1 h 6.4 ± 1.5 mmol/L (115.3 ± 26.6 mg/dL), and 2 h 5.7 ± 1.1 mmol/L (103.5 ± 19.6 mg/dL). Reference intervals for HbA1c, expressed as median and 2.5th to 97.5th percentile for each trimester were: T1: 5.1 (4.5-5.6%), T2: 5.0 (4.4-5.5%), and T3: 5.1 (4.5-5.6%). CONCLUSIONS: The reference range of HbA1C in healthy Mexican pregnant women during pregnancy was 4.4% to 5.6%. We suggest as upper limits of HbA1c value ≤5.6%, 5.5%, and 5.7% for T1, T2, and T3, respectively among Mexican pregnant women.

Implicit bias and its relation to health disparities: a teaching program and survey of medical students.

BACKGROUND: The varying treatment of different patients by the same physician are referred to as within provider disparities. These differences can contribute to health disparities and are thought to be the result of implicit bias due to unintentional, unconscious assumptions. PURPOSES: The purpose is to describe an educational intervention addressing both health disparities and physician implicit bias and the results of a subsequent survey exploring medical students' attitudes and beliefs toward subconscious bias and health disparities. METHODS: A single session within a larger required course was devoted to health disparities and the physician's potential to contribute to health disparities through implicit bias. Following the session the students were anonymously surveyed on their Implicit Association Test (IAT) results, their attitudes and experiences regarding the fairness of the health care system, and the potential impact of their own implicit bias. The students were categorized based on whether they disagreed ("deniers") or agreed ("accepters") with the statement "Unconscious bias might affect some of my clinical decisions or behaviors." Data analysis focused specifically on factors associated with this perspective. RESULTS: The survey response rate was at least 69%. Of the responders, 22% were "deniers" and 77% were "accepters." Demographics between the two groups were not significantly different. Deniers were significantly more likely than accepters to report IAT results with implicit preferences toward self, to believe the IAT is invalid, and to believe that doctors and the health system provide equal care to all and were less likely to report having directly observed inequitable care. CONCLUSIONS: The recognition of bias cannot be taught in a single session. Our experience supports the value of teaching medical students to recognize their own implicit biases and develop skills to overcome them in each patient encounter, and in making this instruction part of the compulsory, longitudinal undergraduate medical curriculum.

Racial Implicit Bias and Communication Among Physicians in a Simulated Environment.

Importance: Racial implicit bias can contribute to health disparities through its negative influence on physician communication with Black patients. Interventions for physicians to address racial implicit bias in their clinical encounters are limited by a lack of high-fidelity (realistic) simulations to provide opportunities for skill development and practice. Objective: To describe the development and initial evaluation of a high-fidelity simulation of conditions under which physicians might be influenced by implicit racial bias. Design, Setting, and Participants: This cross-sectional study, performed on an online platform from March 1 to September 30, 2022, recruited a convenience sample of physician volunteers to pilot an educational simulation. Exposures: In the simulation exercise, physicians saw a 52-year-old male standardized patient (SP) (presenting as Black or White) seeking urgent care for epigastric pain, nausea, and vomiting. The case included cognitive stressors common to clinical environments, including clinical ambiguity, stress, time constraints, and interruptions. Physicians explained their diagnosis and treatment plan to the SP, wrote an assessment and management plan, completed surveys, and took the Race Implicit Association Test (IAT) and Race Medical Cooperativeness IAT. The SPs, blinded to the purpose of the study, assessed each physician's communication using skills checklists and global rating scales. Main Outcomes and Measures: Association between physicians' IAT scores and SP race with SP ratings of communication skills. Results: In 60 physicians (23 [38.3%] Asian, 4 [6.7%] Black, 23 [38.3%] White, and 10 [16.7%] other, including Latina/o/x, Middle Eastern, and multiracial; 31 [51.7%] female, 27 [45.0%] male, and 2 [3.3%] other), the interaction of physicians' Race IAT score and SP race was significant for overall communication (mean [SD] ß = -1.29 [0.41]), all subdomains of communication (mean [SD] ß = -1.17 [0.52] to -1.43 [0.59]), and overall global ratings (mean [SD] ß = -1.09 [0.39]). Black SPs rated physicians lower on communication skills for a given pro-White Race IAT score than White SPs; White SP ratings increased as physicians' pro-White bias increased. Conclusions and Relevance: In this cross-sectional study, a high-fidelity simulation calibrated with cognitive stressors common to clinical environments elicited the expected influence of racial implicit bias on physicians' communication skills. The outlined process and preliminary results can inform the development and evaluation of interventions that seek to address racial implicit bias in clinical encounters and improve physician communication with Black patients.

Emotion regulation and social knowledge in youth at clinical high-risk for psychosis and outpatients with chronic schizophrenia: Associations with functional outcome and negative symptoms.

AIM: Previous studies indicate that several aspects of social cognition are associated with poor social and vocational outcome in the chronic phase of psychosis. However, it is less clear whether specific aspects of social cognition are impaired in those at clinical high-risk (CHR) for psychosis and associated with functioning. The current study evaluated two understudied components of social cognition, emotion regulation knowledge and social knowledge, to determine whether CHR and chronic schizophrenia (SZ) samples demonstrated comparable magnitudes of impairment and associations with functioning. METHODS: Two studies were conducted. Study 1 included n = 98 outpatients with chronic SZ and n = 88 demographically matched healthy controls (CN). Study 2 included 30 CHR and 30 matched CN participants. In both studies, participants completed the emotion management and social management subtests of the Mayer-Salovey-Caruso Emotional Intelligence Test to assess emotion regulation knowledge and social knowledge, respectively. A battery of clinical interviews was also administered, including measures of: role and social functioning, positive symptoms, negative symptoms, disorganization and general symptoms. RESULTS: Individuals with SZ demonstrated lower emotion management and social management scores than CN participants. CHR demonstrated lower scores in social management than CN but did not display deficits in emotion management. In both studies, reduced social knowledge was associated with worse functioning and negative symptoms. CONCLUSIONS: Findings indicate that deficits in social knowledge are transphasic across the SZ spectrum, and are associated with clinical functioning. Social knowledge may be a novel treatment target for psychosocial interventions.

Consensus on Social Determinants of Health Knowledge Topics and Behavior Learning Goals Across Primary Care Residencies: Results of a Delphi Study.

PURPOSE: Social determinants of health (SDH) are a substantial contributor to health outcomes and health inequities across populations. The Accreditation Council for Graduate Medical Education has called for the incorporation of SDH into graduate medical education (GME), yet there is no consensus on what SDH knowledge or skills residents in primary care specialties should have on completion of training. The aim of this study was to develop expert consensus on the most important SDH knowledge topics and behavior learning goals for residents in 4 primary care fields. METHOD: The authors used a modified Delphi technique to develop consensus among experts in internal medicine, pediatrics, family medicine, and obstetrics and gynecology across the United States via a survey administered between February and October 2021. They conducted a literature review on SDH in GME to develop an initial set of topics and learning goals and recruited experts who published about SDH and GME or led an SDH curriculum in GME. Consensus was determined a priori as 80% agreement that a topic or learning goal was very or extremely important. RESULTS: Forty-one experts participated in the first round of the survey and 33 participated in the second round (80% retention). Experts reached consensus on the importance of 22/51 (43%) topics and 18/47 (38%) learning goals. Topics reaching consensus emphasized structural forces, broad domains of SDH, resources for addressing SDH, and advocacy strategies and resources. Learning goals reaching consensus focused on individual- and interpersonal-level behaviors. CONCLUSIONS: To the authors' knowledge, this study represents the first rigorous evaluation of expert consensus on SDH in GME across 4 primary care specialties. The results could inform curriculum development and implementation and program evaluation, residency program goals, and shared GME milestones. Among other things, future studies can assess expert consensus on SDH in GME across nonprimary care specialties.

Natural Drying of Astringent and Non-Astringent Persimmon "Rojo Brillante". Drying Kinetics and Physico-Chemical Properties.

Persimmon (Diospyros kaki L.f.) crop has markedly increased in Spain, and "Rojo Brillante" persimmon is the main cultivated variety. This astringent cultivar requires de-astringency treatment before commercialization, which may involve an extra cost. Its short commercial season implies handling large volumes of fruits with consequent postharvest losses. Therefore, the development of derived added-value products is of much interest. In this study, astringent and non-astringent "Rojo Brillante" persimmons were dehydrated by following a natural drying method used in Asia. The drying kinetics and physico-chemical properties were analyzed for 81 days. The results indicated subsequent reductions in weight, water content, and water activity throughout the drying process, and the equatorial diameter decreased. All the employed thin-layer mathematical models were suitable for representing the drying characteristics of both products with similar behavior. The effective water diffusivity values were 5.07 × 10-11 m2 s-1 and 6.07 × 10-11 m2 s-1 for astringent and non-astringent persimmon samples, respectively. The drying treatment significantly decreased the soluble tannins content, and the astringent samples obtained similar values to those obtained for the non-astringent samples in 20 days. The external and internal flesh of the astringent fruit remained orange through the drying period, while brown coloration in the non-astringent fruit was observed after 57 drying days. Therefore, prior de-astringency treatment would not be necessary.

How Assumptions and Preferences Can Affect Patient Care: An Introduction to Implicit Bias for First-Year Medical Students.

Introduction: Instruction in implicit bias is becoming prevalent across the spectrum of medical training. Little education exists for preclinical students, and guidance for faculty to facilitate such education is minimal. To address these gaps, we designed and delivered a single session for incoming first-year medical students and developed a facilitator training program. Methods: One faculty member delivered a 1-hour, multimedia, interactive lecture to all first-year medical students. Students subsequently met in small groups with trained facilitators. Activities included reflection, guided debriefing, and strategy identification to become aware of when they might be making an assumption causing them to jump to a conclusion about someone. The program evaluation consisted of aggregated student strategies and facilitator feedback during postsession debriefs, both analyzed through thematic analysis. Results: We delivered instruction to 1,098 students. Student strategies resulted in three themes: (1) humility, (2) reflection, and (3) partnering. The postsession debriefs uncovered opportunities to enhance the session. Lessons learned included presenting material to an entire class at once, allowing students to engage in dynamic discussion in the small groups, eliminating anonymous polling in the small groups, and highlighting management of implicit bias as essential to professional development. Discussion: Our instructional design enabled first-year medical students to identify at least one strategy to use when implicit biases are activated. The large-group session was deliverable by one faculty member, and volunteers successfully facilitated small-group sessions after only one training session, making this model a feasible innovation to reach an entire medical school class at the same time.