Diversity, Equity and Inclusion Articles of Interest
The Reporting of Race and Ethnicity in Medical and Science Journals: Comments Invited . Flanagin A, et al. JAMA. 2021 Mar 16;325(11):1049-1052.
Terminology, usage, and word choice are critically important in scientific literature, especially when describing people and when discussing race and ethnicity. The indistinct construct of racial and ethnic categories has been increasingly acknowledged, and the AMA Manual of Style: A Guide for Authors and Editors provides guidance to authors and editors, including regarding usage and reporting of race and ethnicity.
The AMA Style Committee has recently revised the entire subsection on race/ethnicity, and the revised section on inclusive language addresses correct and preferred usage of terms related to race and ethnicity, sex and gender, sexual orientation, age, socioeconomic status, and persons with diseases, disorders, or disabilities. Flanagin et al here provide the revised subsection on race/ethnicity and invite comments on ways this guidance could be improved.
Pediatric Social Risk Screening: Leveraging Research to Ensure Equity . Cullen D, et al. Acad Pediatr. 2021 Sep 24:S1876-2859(21)00452-6. Epub ahead of print.
The Covid-19 pandemic and concurrent economic recession have exacerbated the effects of poverty on child health. There is additional pressure to implement screening protocols for social risk factors within pediatric health care. The effect of standardized social risk screening on resource engagement is unknown.
Cullen and coauthors describe three potential sources of inequity related to screening for social risk interventions. First, there is a discordance between screening results and the desire for services. This discordance occurs in both directions, with some participants screening positive but not reporting a specific “need” for services, and other participants having social needs but screening negative. Second, there is a discomfort with screening present across many participants but highest in those who report social risk due largely to fear of judgment and involvement of child protective services. Finally, screening discrimination at the healthcare level occurs as social risk screening practices are more commonly implemented in clinical settings with a majority of non-white clientele. Black and Brown children are more likely to be referred to child protective services and less likely to either stay with their parents or be reunified with them after foster care. The authors close with a recommendation for ethical, patient-centered approaches to implementing social needs interventions.
Promoting Equity for Women in Medicine - Seizing a Disruptive Opportunity. Jagsi R. N Engl J Med. 2021 Jun 17;384(24):2265-2267.
Women are underrepresented in the science, technology, engineering, mathematics, and medical (STEMM) fields, particularly in leadership positions. Disruptions associated with the Covid-19 pandemic have had a disproportionate effect on women’s personal and professional lives.
In 2020, the National Academies of Sciences, Engineering, and Medicine (NASEM) published a report containing ideas for addressing long-standing issues of underrepresentation in the STEMM fields. Examining these practices is particularly important in light of changing responsibilities and a workplace culture that has accompanied the Covid-19 pandemic. Since the onset of the pandemic, women have played an outsized role in adapting to the changing needs of family members, patients, students, and colleagues, and there is growing evidence that these changes may result in lasting, negative consequences for career trajectories. Specific challenges include increased workload, reduced academic productivity, changes in interpersonal interactions, and difficulties associated with remote work. Institutional response to the pandemic has varied, but many organizations have missed opportunities to apply equity-minded leadership principles in the rush to manage the crisis. The authors in this Perspective piece published in the New England Journal of Medicine urge those of us in the academic medicine community to combat bias in selection and promotion processes, seek input from diverse stakeholders, and consider the long-term consequences of their decisions.
COVID-19 medical papers have fewer women first authors than expected. Andersen JP. Elife. 2020 Jun 15;9:e58807.
There is significant evidence demonstrating that women in academic medicine shoulder a larger burden of domestic labor within their households than do men. The shift in social responsibilities related to the Covid-19 pandemic may disproportionately affect the scholarly productivity of women medical researchers as compared to men.
This paper compares the gender distribution of the authors of 1893 medical papers related to the Covid-19 pandemic to papers published in the same journals in 2019. Analysis showed that the proportion of Covid-19 papers with a woman first author was 19% lower than that for papers published in the same journals in 2019. These findings give credence to the idea that restricted access to child-care and increased work-related service demands may have taken a greater toll on women researchers as compared to men. There is abundant literature supporting the importance of diverse teams for solving complex problems. The authors of this paper argue that social constraints which disproportionately affect one group (women, for example) over another (men) could have profound negative consequences for our national and global response to the Covid-19 pandemic.
Unequal effects of the COVID-19 pandemic on scientists. Myers KR. Nat Hum Behav. 2020 Sep;4(9):880-883.
Workplace restrictions and personal duties have changed during the Covid-19 pandemic, particularly in the early months of the pandemic. Scientists have not been immune to these shifting responsibilities, and evidence is needed on the magnitude of the disruption scientists are experiencing.
The authors of this paper conducted a survey of US- and Europe-based scientists to determine the extent of disruptions scientists experienced due to the Covid-19 pandemic. This survey was conducted in April of 2020, approximately one month after the WHO declared Covid-19 a pandemic. Results of the survey showed a decline in total working hours (61 hours/week to 54), a larger effect in research time for bench scientists (researchers whose work relies on physical laboratories and time-sensitive experiments), and a larger effect on female scientists and scientists with young dependents. The authors suggest several specific remedies, including enhanced childcare programs and tenure clock extensions for junior faculty.
Combating Anti-Asian Sentiment — A Practical Guide for Clinicians. Lee JH. N Engl J Med. Published online March 24, 2021. NEJMp2102656.
Commentators have attributed recent increases in anti-Asian discrimination and violence to the blame placed on China for causing the Covid-19 pandemic, further perpetuated by U.S. officials at the highest levels use terms like the “China Virus” and “Kung Flu”. But Asian discrimination against Asian communities far precedes the recent COVID-19 pandemic, and in fact, has occurred for decades even outside the context of infectious diseases. Nevertheless, racism in the U.S. has been largely characterized along a Black/White binary, which has contributed to the increasing recognition of anti-Black racism as deeply embedded within societal structure, while inadvertently leading to the under-recognition and under-reporting of Anti-Asian racism.
Dr. Lee, who is a psychiatrist in the University of Washington, Seattle, proposes a framework that can be employed by clinicians to combat Anti-Asian racism. This framework includes tips such as: creating a safe space in outpatient settings (e.g. hanging welcoming signage), creating a safe space in inpatient settings (e.g. separating patients who display discriminatory attitudes or make discriminatory remarks from patients of color), addressing racism both during history taking (by asking directly if the patient has been affected by it) and examination, augmenting cultural competency (e.g. bystander training, crisis de-escalation, etc.) training for staff and offering institutional support to those who experience hate crimes, and providing resources specifically addressing anti-Asian sentiment (e.g. https://stopaapihate.org/)
Prevalence and Nature of Sexist and Racial/Ethnic Microaggressions Against Surgeons and Anesthesiologists . Sudol et al. JAMA Surg. Published online March 24, 2021.
Microaggressions are subtle, insulting, discriminatory comments or actions that communicate a demeaning or hostile message to non-dominant groups. Microaggressions are known to cause chronic, severe distress, and ultimately physician burnout.
This paper describes the results of a primary survey study, which included 588 respondents (80 anesthesiologists and the remaining surgeons of different specialties) and used the Racial Microaggression Scale, the Sexist Microaggression Experience and Stress Scale, and the Maslach Burnout Inventory to assess the prevalence of microaggressions among surgeons and anesthesiologists, as well as its relationship with burnout. The study found 94% of women respondents experienced sexist microaggressions and 81% of racial/ethnic minority respondents experienced racial/ethnic microaggressions, respectively. Burnout was higher among women and racial-ethnic minority physicians at baseline, but even higher among those who experienced either sexist or racial/ethnic microaggressions, and higher still among women physicians who experienced both.
Without Sanctuary . Ogunwole SM. N Engl J Med. 2021;384(9):791–3.
The impact of racism and racial discrimination on physicians, as well as patients, has been well described. But the intersection of both, and their impact on patient care has been less explored.
In this candid yet powerful perspective, Dr. Ogunwole, a Black Internal Medicine physician at the Johns Hopkins University, describes an experience during her residency that affected her strongly. She recalls Ms. A, a young Black woman with sickle cell anemia, being the victim of racial profiling by her nurse and ultimately by hospital security staff. She was accused of taking opioid pain medication not prescribed to her during her admission, physically restrained, and violently pinned to the ground despite having critically low platelets and a high risk of bleeding. In the words of Dr. Ogunwole, “In quiet moments, I often reflect on how our society decides who deserves punishment and who deserves redemption. I think about grace, and how Black people get so little. I think about trust, and how Black people get so little. I think about the benefit of the doubt, and how Black people get so little. And I think about the varied manifestations of Ms. A.’s pain — how no one, me included, offered her a sanctuary.”
Physician-Patient Racial Concordance and Disparities in Birthing Mortality for Newborns , Greenwood et al. Proc Natl Acad Sci U S A. 2020 Sep 1;117(35):21194-21200.
Recent work has shown evidence of the effect of patient-physician gender and racial concordance in medicine. Concordance can reduce outgroup biases, boost communication, and increase trust. Limited evidence exists that these benefits translate into material health benefits.
This work investigates the potential for patient-physician racial concordance to ameliorate healthcare disparities experienced by Black newborns, who die at three times the rate of White newborns in the United States. Investigators examined 1.8 million births in Florida hospitals from 1992-2015. The primary interest was whether the Black-White newborn mortality risk differs depending on physician race. Researchers found a robust racial concordance benefit for Black newborns being cared for by Black physicians as compared to Black newborns being cared for by White physicians. In the simplest model, this amounted to a difference of 257 deaths per 100,000 births, a 58% reduction in the racial mortality difference. Results further suggest that these benefits manifest during more challenging births and in hospitals that deliver more Black babies. This work gives strength to the call for hospitals, medical schools, and other healthcare organizations to build robust pipelines and pathways for Black students in medicine, reduce biases, and dismantle institutional racism.
Disability and Diversity studies as a professional basis for diversity-aware education and training in medicine . Dungs et al. GMS J Med Educ 2020; 37(2)
People with disabilities who have negative experiences in the health care system, such as lack of sensitivity, disrespect, and devaluation, often choose to not seek professional medical care. An inability to distinguish symptoms from the disability or other diseases, limited knowledge of the disabled person’s life, and communication problems result in suboptimal patient-doctor relationships and treatment plans.
Disability and Diversity Studies (DDS) aim to move away from the medical model to the social model of disability. The medical model emphasizes the physical illness or disability, whereas the social model focuses on social disadvantages and barriers. In the DDS program, affected persons define their needs and request support, as opposed to predefined institutional patient care plans that are often biased and based on categorical assumptions. “The focus is on assistance models that enable those affected to lead a self-determined and supported life according to their needs.” The principle “Nothing about us, without us!” is recommended in the training of all health care professionals. The DDS Bachelor’s program curriculum at the Carinthia University of Applied Sciences is outlined in this paper. Inclusion of people with disabilities in medical education is deemed essential to acquire the following six fields of competence for respectful, patient-centered care.
- Contextual and conceptual framework for disabilities
- Professionalism and patient-centered care
- Legal obligations and responsibilities for the care of patients with disabilities
- Teams and system-based practice
- Clinical evaluation
- Clinical care over the life span and during changes.These principles should be applied in the treatment of people with any disability (i.e. physical, mental, addiction, economic, social, etc.).
- Flanagin A, Frey T, Christiansen SL, et al. The Reporting of Race and Ethnicity in Medical and Science Journals: Comments Invited. JAMA. 2021;325(11):1049-1052. [PMID:33616604]
- Cullen D, Wilson-Hall L, McPeak K, et al. Pediatric Social Risk Screening: Leveraging Research to Ensure Equity. Acad Pediatr. 2021. [PMID:34571253]
- Jagsi R, Fuentes-Afflick E, Higginbotham E. Promoting Equity for Women in Medicine - Seizing a Disruptive Opportunity. N Engl J Med. 2021;384(24):2265-2267. [PMID:34134182]
- Andersen JP, Nielsen MW, Simone NL, et al. COVID-19 medical papers have fewer women first authors than expected. Elife. 2020;9. [PMID:32538780]
- Myers KR, Tham WY, Yin Y, et al. Unequal effects of the COVID-19 pandemic on scientists. Nat Hum Behav. 2020;4(9):880-883. [PMID:32669671]
- Lee JH. Combating Anti-Asian Sentiment - A Practical Guide for Clinicians. N Engl J Med. 2021;384(25):2367-2369. [PMID:33761204]
- Sudol NT, Guaderrama NM, Honsberger P, et al. Prevalence and Nature of Sexist and Racial/Ethnic Microaggressions Against Surgeons and Anesthesiologists. JAMA Surg. 2021;156(5):e210265. [PMID:33760000]
- Ogunwole SM. Without Sanctuary. N Engl J Med. 2021;384(9):791-793. [PMID:33657685]
- Greenwood BN, Hardeman RR, Huang L, et al. Physician-patient racial concordance and disparities in birthing mortality for newborns. Proc Natl Acad Sci U S A. 2020;117(35):21194-21200. [PMID:32817561]
- Dungs S, Pichler C, Reiche R. Disability & Diversity studies as a professional basis for diversity-aware education and training in medicine. GMS J Med Educ. 2020;37(2):Doc23. [PMID:32328525]