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Physician and Trainee Experiences With Patient Bias.

ABSTRACT: Importance:As the clinical workforce becomes more diverse, physicians encounter patients who demean them based on social characteristics. Little is known about physicians' perspectives on these encounters and their effects. This knowledge would help develop policies and best practices for institutions and training programs. Objective:To describe the range and importance of encounters with biased patients and the barriers and facilitators to effective responses. Design, Setting, and Participants:This qualitative study recruited convenience samples of hospitalist attending physicians, internal medicine residents, and medical students from 3 campuses affiliated with 1 academic medical center. Data were collected from 50 individuals within 13 focus groups from May 9 through October 15, 2018. Focus groups were conducted using open-ended probes, audiotaped, and transcribed. Participants used their own definition of biased patient behavior. Each transcript was independently coded by at least 2 investigators. Data were analyzed from May 2018 through February 2019. Main Outcomes and Measures:Major themes associated with types of encounter, importance to the participant, and barriers and facilitators to effective responses were abstracted through the constant comparative approach. Results:Overall, 50 individuals (11 hospitalists, 26 residents, and 13 students) participated; 24 (48%) were nonwhite. At total of 26 participants (52%) identified as women; 22 (44%), as men; and 2 (4%), as gender nonconforming. Reports of biased behavior ranged from patient refusal of care and explicit racist, sexist, or homophobic remarks to belittling compliments or jokes. Targeted physicians reported an emotional toll that included exhaustion, self-doubt, and cynicism. Nontargeted bystanders reported moral distress and uncertainty about how to respond. Participant responses ranged from withdrawal from clinical role to a heightened determination to provide standard of care. Barriers to effective responses included lack of skills, insufficient support from senior colleagues and the institution, and perception of lack of utility associated with responding. Participants expressed a need for training on dealing with biased patients and for clear institutional policies to guide responses. Conclusions and Relevance:In this qualitative study of physicians and medical students, encounters with demeaning patients ranged from refusal of care to belittling jokes and were highly challenging and painful. Addressing biased patient behavior will require a concerted effort from medical schools and hospitals to create policies and trainings conducive to a clinical environment that respects the diversity of patients and physicians alike.

SUBMITTER: Wheeler M

PROVIDER: S-EPMC6820043 | biostudies-literature | 2019 Oct

REPOSITORIES: biostudies-literature

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Physician and Trainee Experiences With Patient Bias.

Wheeler Margaret M de Bourmont Shalila S Paul-Emile Kimani K Pfeffinger Alana A McMullen Ashley A Critchfield Jeff M JM Fernandez Alicia A

JAMA internal medicine 20191201 12

<h4>Importance</h4>As the clinical workforce becomes more diverse, physicians encounter patients who demean them based on social characteristics. Little is known about physicians' perspectives on these encounters and their effects. This knowledge would help develop policies and best practices for institutions and training programs.<h4>Objective</h4>To describe the range and importance of encounters with biased patients and the barriers and facilitators to effective responses.<h4>Design, setting, ...[more]

PMID: 31657839

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Project description:BackgroundMicro- and macroaggressions are often stereotype threats that can have detrimental effects on the recipients. Survey data shows that these aggressions are happening. However, there are few qualitative studies on trainees and faculty physicians' experiences with such aggressions and their impact.ObjectiveExplore how micro- and macroaggressions impact physician trainees and faculty.Design, setting, participantsVirtual, one-on-one, semi-structured interviews were conducted between February and September 2021, among 14 physicians and trainees (medical students, residents, fellows, and faculty) at a tertiary, urban, US academic medical center and its associated hospitals. Participants shared their experiences with micro- and macroaggressions in training and the workplace, as well as their thoughts on intervention and education.ApproachQualitative interviews; grounded theory approach KEY RESULTS: A total of 14 physicians and trainees (5 faculty, 2 fellows, 5 residents, 2 students; 11 [79%] women) participated. Four themes with multiple subthemes surfaced: definition, the moment an aggression is experienced, aftereffect of an aggression, and education and training. While general definitions of micro- and macroaggressions were similar among participants, some may have overlooked the inclusion of a marginalized group as central to each term. Both types of aggressions had a range of effects on participants, with faculty noting a cumulative effect. Institutional diversity was identified as a key source of support. Ideas on how to combat such acts included mandatory educational programs and policies, with the acknowledgment that much effort and time are necessary to change mindset and culture.ConclusionsFaculty physicians and medical trainees shared their personal experiences with micro- and macroaggressions during work and training. Participants described various emotions in the moment but also noted that these aggressions often had lasting impacts. They recognized the challenges of finding a solution to micro- and macroaggressions. Institution-wide education was favored by many as a first step.

Project description:ImportanceEvaluation of trainees in graduate medical education training programs using Milestones has been in place since 2013. It is not known whether trainees who have lower ratings during the last year of training go on to have concerns related to interactions with patients in posttraining practice.ObjectiveTo investigate the association between resident Milestone ratings and posttraining patient complaints.Design, setting, and participantsThis retrospective cohort study included physicians who completed Accreditation Council for Graduate Medical Education (ACGME)-accredited programs between July 1, 2015, and June 30, 2019, and worked at a site that participated in the national Patient Advocacy Reporting System (PARS) program for at least 1 year. Milestone ratings from ACGME training programs and patient complaint data from PARS were collected. Data analysis was conducted from March 2022 to February 2023.ExposuresLowest professionalism (P) and interpersonal and communication skills (ICS) Milestones ratings 6 months prior to the end of training.Main outcomes and measuresPARS year 1 index scores, based on recency and severity of complaints.ResultsThe cohort included 9340 physicians with median (IQR) age of 33 (31-35) years; 4516 (48.4%) were women physicians. Overall, 7001 (75.0%) had a PARS year 1 index score of 0, 2023 (21.7%) had a score of 1 to 20 (moderate), and 316 (3.4%) had a score of 21 or greater (high). Among physicians in the lowest Milestones group, 34 of 716 (4.7%) had high PARS year 1 index scores, while 105 of 3617 (2.9%) with Milestone ratings of 4.0 (proficient), had high PARS year 1 index scores. In a multivariable ordinal regression model, physicians in the 2 lowest Milestones rating groups (0-2.5 and 3.0-3.5) were statistically significantly more likely to have higher PARS year 1 index scores than the reference group with Milestones ratings of 4.0 (0-2.5 group: odds ratio, 1.2 [95% CI, 1.0-1.5]; 3.0-3.5 group: odds ratio, 1.2 [95% CI, 1.1-1.3]).Conclusions and relevanceIn this study, trainees with low Milestone ratings in P and ICS near the end of residency were at increased risk for patient complaints in their early posttraining independent physician practice. Trainees with lower Milestone ratings in P and ICS may need more support during graduate medical education training or in the early part of their posttraining practice career.

Project description:ImportancePeer relationships may motivate physicians to aspire to high professional standards but have not been a major focus of quality improvement efforts.ObjectiveTo determine whether peer relationships between primary care physicians (PCPs) and specialists formed during training motivate improved specialist care for patients.Design, setting, and participantsIn this quasi-experimental study, difference-in-differences analysis was used to estimate differences in experiences with specialist care reported by patients of the same PCP for specialists who did vs did not co-train with the PCP, controlling for any differences in patient ratings of the same specialists in the absence of co-training ties. Specialist visits resulting from PCP referrals from 2016 to 2019 in a large health system were analyzed, including a subset of undirected referrals in which PCPs did not specify a specialist. Data were collected from January 2016 to December 2019 and analyzed from March 2020 to October 2022.ExposureThe exposure was PCP-specialist overlap in training (medical school or postgraduate medical) at the same institution for at least 1 year (co-training).Main outcomes and measuresComposite patient experience rating of specialist care constructed from Press Ganey's Medical Practice Survey.ResultsOf 9920 specialist visits for 8655 patients (62.9% female; mean age, 57.4 years) with 502 specialists in 13 specialties, 3.1% (306) involved PCP-specialist dyads with a co-training tie. Co-training ties between PCPs and specialists were associated with a 9.0 percentage point higher adjusted composite patient rating of specialist care (95% CI, 5.6-12.4 percentage points; P < .001), analogous to improvement from the median to the 91st percentile of specialist performance. This association was stronger for PCP-specialist dyads with full temporal overlap in training (same class or cohort) and consistently strong for 9 of 10 patient experience items, including clarity of communication and engagement in shared decision-making. In secondary analyses of objective markers of altered specialist practice in an expanded sample of visits not limited by the availability of patient experience data, co-training was associated with changes in medication prescribing, suggesting behavioral changes beyond interpersonal communication. Patient characteristics varied minimally by co-training status of PCP-specialist dyads. Results were similar in analyses restricted to undirected referrals (in which PCPs did not specify a specialist). Concordance between PCPs and specialists in physician age, sex, medical school graduation year, and training institution (without requiring temporal overlap) was not associated with better care experiences.Conclusions and relevanceIn this quasi-experimental study, PCP-specialist co-training elicited changes in specialist care that substantially improved patient experiences, suggesting potential gains from strategies encouraging the formation of stronger physician-peer relationships.

Project description:BackgroundRecently, there have been concerted efforts to improve racial and ethnic diversity in the physician-scientist workforce. Identifying factors associated with career choices among those underrepresented in medicine and science is a necessary first step to advance this objective. The aim of the present study was to assess the attitudes and factors associated with academic and research career interests among underrepresented predoctoral physician-scientists.MethodsA cross-sectional 70-question survey was distributed to all predoctoral single degree (MD or DO) and dual degree (MD/PhD or DO/PhD) trainees at 32 medical schools in the United States from 2012 to 2014. Main outcomes included factors important to advancement in academic medicine, intended medical specialty, and future career plans. To test the post-hoc hypothesis of whether trainees from underrepresented groups have differing perceptions of career trajectories and obstacles than their counterparts, we evaluated responses according to self-identified race/ethnic status using Chi-square and Fisher's exact tests. All tests were two-sided and significance level of < 0.05 was used.ResultsThere were a total of 4433 responses representing all predoctoral training stages. The response rate was 27%. Most respondents were single degree trainees (MD/DO 79% vs MD/DO-PhD 21%). Most respondents self-identified as White (67%), followed by Multi-racial or Other (14.3%), Asian or Pacific Islander (10.4%), Hispanic (6%), and Black or African American (4.1%). Desired career sector, career intention, and clinical specialty interest differed across race/ethnic groups. With respect to career selection factors, anticipated non-work related responsibilities during residency were also significantly different between these groups. By multivariable regression analysis, Black or African American trainees were significantly less likely than White trainees to indicate a career in academia (OR 0.496, 95% CI 0.322-0.764) and basic research (OR 0.314, 95% CI 0.115-0.857), while Multi-racial or Other trainees were also less likely than White trainees to indicate a career in academia (OR 0.763, 95% CI 0.594-0.980).ConclusionsThese data represent the first in-depth survey of career aspirations, perceptions, and interests between demographically underrepresented and non-underrepresented predoctoral physician-scientist trainees. Our results identify key differences between these cohorts, which may guide efforts to improve diversity within the physician-scientist workforce.

Project description:The coronavirus disease 2019 (COVID-19) pandemic has put considerable physical and emotional strain on frontline healthcare workers. Among frontline healthcare workers, physician trainees represent a unique group-functioning simultaneously as both learners and caregivers and experiencing considerable challenges during the pandemic. However, we have a limited understanding regarding the emotional effects and vulnerability experienced by trainees during the pandemic. We investigated the effects of trainee exposure to patients being tested for COVID-19 on their depression, anxiety, stress, burnout and professional fulfillment. All physician trainees at an academic medical center (n = 1375) were invited to participate in an online survey. We compared the measures of depression, anxiety, stress, burnout and professional fulfillment among trainees who were exposed to patients being tested for COVID-19 and those that were not, using univariable and multivariable models. We also evaluated perceived life stressors such as childcare, home schooling, personal finances and work-family balance among both groups. 393 trainees completed the survey (29% response rate). Compared to the non-exposed group, the exposed group had a higher prevalence of stress (29.4% vs. 18.9%), and burnout (46.3% vs. 33.7%). The exposed group also experienced moderate to extremely high perceived stress regarding childcare and had a lower work-family balance. Multivariable models indicated that trainees who were exposed to COVID-19 patients reported significantly higher stress (10.96 [95% CI, 9.65 to 12.46] vs 8.44 [95% CI, 7.3 to 9.76]; P = 0.043) and were more likely to be burned out (1.31 [95% CI, 1.21 to1.41] vs 1.07 [95% CI, 0.96 to 1.19]; P = 0.002]. We also found that female trainees were more likely to be stressed (P = 0.043); while unmarried trainees were more likely to be depressed (P = 0.009), and marginally more likely to have anxiety (P = 0.051). To address these challenges, wellness programs should focus on sustaining current programs, develop new and targeted mental health resources that are widely accessible and devise strategies for creating awareness regarding these resources.

Project description:Background3D printed models are becoming increasingly popular in healthcare as visual and tactile tools to enhance understanding of anatomy and pathology in medical trainee education, provide procedural simulation training, and guide surgical procedures. Patient-specific 3D models are currently being used preoperatively for trainee medical education in planning surgical approaches and intraoperatively to guide decision-making in several specialties. Our study group utilized a modified Delphi process to create a standardized assessment for trainees using patient-specific 3D models as a tool in medical education during pre-surgical planning.MethodsA literature review was conducted to identify survey questions administered to clinicians in published surgical planning studies regarding the use of patient-specific 3D models. A core study team reviewed these questions, removed duplicates, categorized them, mapped them to overarching themes, and, where applicable, modified individual questions into a form generalizable across surgical specialties. The core study panel included a physician, physician-scientist, social scientist, engineer/medical student, and 3D printing lab manager. A modified Delphi process was then used to solicit feedback on the clarity and relevance of the individual questions from an expert panel consisting of 12 physicians from specialties including anesthesiology, emergency medicine, radiology, urology, otolaryngology, and obstetrics/gynecology. When the Radiological Society of North America (RSNA)/American College of Radiology (ACR) 3D Printing Registry Data Dictionary was released, additional survey questions were reviewed. A final cross-disciplinary survey of the utility of 3D printed models in surgical planning medical education was developed.ResultsThe literature review identified 100 questions previously published in surveys assessing patient-specific 3D models for surgical planning. Following the review, generalization, and mapping of survey questions from these studies, a list of 24 questions was generated for review by the expert study team. Five additional questions were identified in the RSNA/ACR 3D Printing Registry Data Dictionary and included for review. A final questionnaire consisting of 20 questions was developed.ConclusionsAs 3D printed models become more common in medical education, the need for standardized assessment is increasingly essential. The standardized questionnaire developed in this study reflects the interests of a variety of stakeholders in patient-specific 3D models across disciplines.

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Physician and Trainee Experiences With Patient Bias.

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Physician and Trainee Experiences With Patient Bias.

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