An Analysis of Implicit Bias in Medical Education

Background: The Implicit Association Test (IAT) is a well-researched method of identifying an individual\u27s implicit bias. Occurring outside of conscious awareness, implicit bias manifests itself in the form of nonverbal thoughts, behaviors and actions that influence an individual and that are suggestive of unequal treatment. In the undergraduate medical education curriculum, the IAT is commonly used to assess the medical students\u27 personal bias. Studies from the American Association of Medical Colleges (AAMC) have shown that bias is ranked highly as one of the least addressed educational goals in medical education and training. The medical literature suggests that implicit bias affects how clinical faculty make patient care decisions, and that this in turn affects medical student education. Data collected from our medical school\u27s first year curriculum suggest that there are missed opportunities to explore the effects of bias on health outcomes. Objective: The purpose of this study was to analyze comments in reflection papers submitted by students enrolled in the required Determinants of Health (DoH) course during the Fall 2014- Spring 2015 curriculum at the University of Massachusetts Medical School (UMMS). The DoH course assignment asked students to select a reading, experience in taking the IAT or class discussion, and comment on how the material led to new insight about the potential effect of biases or stereotyping on future clinical decisions. The themes from this analysis provided context for relevant areas for further exploration of the impact of implicit bias in medical education. Method: 125 first-year medical students (48% female, 52% male; mean age 25 years; 95% from Massachusetts, 9% identified as under-represented ethnic/racial minorities) in the entering class of 2014 submitted written reflections following attendance and discussion-based learning in the DoH course. Grounded theory methodology was used for the qualitative analysis of the comments. Papers were de-identified, read, and codes were constructed according to emerging themes (descriptive, diagnostic, and prescriptive) found. The codebook development focused on bias, systemic/institutional bias, individual bias, awareness and health disparities . Student commentary was coded for themes and tallied for total amount of discussion for each theme. Inter-rater reliability was calculated for 20% of the sample using Cohen\u27s kappa. Results: The following themes emerged: 1) an understanding of the IAT and the results of the IAT; 2) a definition of bias; 3) a suggestion of source of bias; 4) factors informing bias; and 5) action items to combat the effects of implicit bias on future physicians. Ninety-five of 125 students\u27 comments (76%) mapped to descriptive themes associated with bias; 27% (n=26/95) of comments suggested all individuals have bias; 57% (n=55) of comments suggested potential sources of bias, ranging from cultural and community upbringings to societal media; 83% (n=79) of comments focused on the negative effect implicit bias can have on decision-making in patient care; and nearly 96% (n=91) of comments felt that acknowledging their own implicit bias would benefit their interactions with patients in their future medical careers. Additionally, 58% (n=73/125) of students\u27 comments noted that making a conscious effort to self-reflect and address bias would improve decision-making, and 32% (n=40) of comments noted it was a physician\u27s responsibility to dismantle the bias found in the healthcare system (15 comments suggested this happen through avenues such as advocacy and legislation). Seventy students\u27 comments (56%) mapped to comments discussing the lAT. Forty-three percent (n=30) comments noted students surprised by their results and 29% (n=20) of comments suggested that the student was not surprised. While 75 students (60%) did not comment on their reaction, the IAT sparked self-reflection of implicit bias and its origin in 68 of these students, and 16% (n=20) of comments found the IAT to be a valuable tool in identifying implicit bias. With regard to the current climate ofhealthcare, 40 responding students (32%) identified racism or racial bias existing within the medical field, noting potential sources of racism including lack of trust in physicians from historical events such as the Tuskegee Syphilis Experiment and societal inequalities as a whole. Additionally, 29 students\u27 comments (23%) mentioned systemic/institutional bias as potentially having an impact on individual bias and vice versa. Conclusions: The use of the IAT in the medical education curriculum is informative and the medical student response to it is impactful. Medical students gain insight into the importance of understanding personal implicit bias and the effect it may have on clinical decision-making through courses such as Determinants of Health. Students have the ability and the desire to identify and self-reflect on the development of behaviors and skills that will facilitate improved decision-making in the care of patients, and improved patient interactions. This analysis also points to the significance of further exploration of faculty involvement in these topics to further engage medical students throughout their undergraduate medical training. As over 93% of the first-year medical school courses did not utilize race identifiers and non-medical factors in clinical vignettes, this is another opportunity to apply real-life scenarios to the educational curriculum

Pre-clinical medical student reflections on implicit bias: Implications for learning and teaching

CONTEXT: Implicit bias affects health professionals\u27 clinical decision-making; nevertheless, published reports of medical education curricula exploring this concept have been limited. This research documents a recent approach to teaching implicit bias. METHODS: Medical students matriculating during 2014 and 2015 participated in a determinants of health course including instruction about implicit bias. Each submitted a reflective essay discussing implicit bias, the experience of taking the Implicit Association Test (IAT), and other course content. Using grounded theory methodology, student essays that discussed reactions to the IAT were analyzed for content themes based on specific statements mapping to each theme. Twenty-five percent of essays underwent a second review to calculate agreement between raters regarding identification of statements mapping to themes. OUTCOME: Of 250 essays, three-quarters discussed students\u27 results on the IAT. Theme comments related to: a) experience taking the IAT, b) bias in medicine, and c) prescriptive comments. Most of the comments (84%) related to students\u27 acknowledging the importance of recognizing implicit bias. More than one-half (60%) noted that bias affects clinical decision-making, and one-fifth (19%) stated that they believe it is the physician\u27s responsibility to advocate for dismantling bias. CONCLUSIONS: Through taking the IAT and developing an understanding of implicit bias, medical students can gain insight into the effect it may have on clinical decision-making. Having pre-clinical medical students explore implicit bias through the IAT can lay a foundation for discussing this very human tendency

Rituximab versus intravenous cyclophosphamide in patients with connective tissue disease-associated interstitial lung disease in the UK (RECITAL): a double-blind, double-dummy, randomised, controlled, phase 2b trial

BACKGROUND: Rituximab is often used as rescue therapy in interstitial lung disease (ILD) associated with connective tissue disease (CTD), but has not been studied in clinical trials. This study aimed to assess whether rituximab is superior to cyclophosphamide as a treatment for severe or progressive CTD associated ILD. METHODS: We conducted a randomised, double-blind, double-dummy, phase 2b trial to assess the superiority of rituximab compared with cyclophosphamide. Patients aged 18-80 years with severe or progressive ILD related to scleroderma, idiopathic inflammatory myositis, or mixed CTD, recruited across 11 specialist ILD or rheumatology centres in the UK, were randomly assigned (1:1) to receive rituximab (1000 mg at weeks 0 and 2 intravenously) or cyclophosphamide (600 mg/m2 body surface area every 4 weeks intravenously for six doses). The primary endpoint was rate of change in forced vital capacity (FVC) at 24 weeks compared with baseline, analysed using a mixed-effects model with random intercepts, adjusted for baseline FVC and CTD type. Prespecified secondary endpoints reported in this Article were change in FVC at 48 weeks versus baseline; changes from baseline in 6 min walk distance, diffusing capacity of the lung for carbon monoxide (DLCO), physician-assessed global disease activity (GDA) score, and quality-of-life scores on the St George's Respiratory Questionnaire (SGRQ), King's Brief Interstitial Lung Disease (KBILD) questionnaire, and European Quality of Life Five-Dimension (EQ-5D) questionnaire at 24 and 48 weeks; overall survival, progression-free survival, and time to treatment failure; and corticosteroid use. All endpoints were analysed in the modified intention-to-treat population, which comprised all patients who received at least one dose of study drug. This trial is registered with ClinicalTrials.gov (NCT01862926). FINDINGS: Between Dec 1, 2014, and March 31, 2020, we screened 145 participants, of whom 101 participants were randomly allocated: 50 (50%) to receive cyclophosphamide and 51 (50%) to receive rituximab. 48 (96%) participants in the cyclophosphamide group and 49 (96%) in the rituximab group received at least one dose of treatment and were included in analyses; 43 (86%) participants in the cyclophosphamide group and 42 (82%) participants in the rituximab group completed 24 weeks of treatment and follow-up. At 24 weeks, FVC was improved from baseline in both the cyclophosphamide group (unadjusted mean increase 99 mL [SD 329]) and the rituximab group (97 mL [234]); in the adjusted mixed-effects model, the difference in the primary endpoint at 24 weeks was -40 mL (95% CI -153 to 74; p=0·49) between the rituximab group and the cyclophosphamide group. KBILD quality-of-life scores were improved at 24 weeks by a mean 9·4 points (SD 20·8) in the cyclophosphamide group and 8·8 points (17·0) in the rituximab group. No significant differences in secondary endpoints were identified between the treatment groups, with the exception of change in GDA score at week 48, which favoured cyclophosphamide (difference 0·90 [95% CI 0·11 to 1·68]). Improvements in lung function and respiratory-related quality-of-life measures were observed in both treatment groups. Lower corticosteroid exposure over 48 weeks of follow-up was recorded in the rituximab group. Two (4%) of 48 participants who received cyclophosphamide and three (6%) of 49 who received rituximab died during the study, all due to complications of CTD or ILD. Overall survival, progression-free survival, and time to treatment failure did not significantly differ between the two groups. All participants reported at least one adverse event during the study. Numerically fewer adverse events were reported by participants receiving rituximab (445 events) than those receiving cyclophosphamide (646 events). Gastrointestinal and respiratory disorders were the most commonly reported adverse events in both groups. There were 62 serious adverse events of which 33 occurred in the cyclophosphamide group and 29 in the rituximab group. INTERPRETATION: Rituximab was not superior to cyclophosphamide to treat patients with CTD-ILD, although participants in both treatment groups had increased FVC at 24 weeks, in addition to clinically important improvements in patient-reported quality of life. Rituximab was associated with fewer adverse events. Rituximab should be considered as a therapeutic alternative to cyclophosphamide in individuals with CTD-ILD requiring intravenous therapy. FUNDING: Efficacy and Mechanism Evaluation Programme (Medical Research Council and National Institute for Health Research, UK)

Recurrent Tissue-Specific Mtdna Mutations are Common in Humans

Mitochondrial DNA (mtDNA) variation can affect phenotypic variation; therefore, knowing its distribution within and among individuals is of importance to understanding many human diseases. Intra-individual mtDNA variation (heteroplasmy) has been generally assumed to be random. We used massively parallel sequencing to assess heteroplasmy across ten tissues and demonstrate that in unrelated individuals there are tissue-specific, recurrent mutations. Certain tissues, notably kidney, liver and skeletal muscle, displayed the identical recurrent mutations that were undetectable in other tissues in the same individuals. Using RFLP analyses we validated one of the tissue-specific mutations in the two sequenced individuals and replicated the patterns in two additional individuals. These recurrent mutations all occur within or in very close proximity to sites that regulate mtDNA replication, strongly implying that these variations alter the replication dynamics of the mutated mtDNA genome. These recurrent variants are all independent of each other and do not occur in the mtDNA coding regions. The most parsimonious explanation of the data is that these frequently repeated mutations experience tissue-specific positive selection, probably through replication advantage

The Radioecology Exchange

The Radioecology Exchange (www.radioecology-exchange.org) was created in 2011 under the EU FP7 STAR (STrategy for Allied Radioecology, www.star-radioecology.org) Network of Excellence; (2011-2015). This project aims to integrate radioecological research efforts of European organisations into a sustainable network. In 2013, the EU FP7 COMET (COordination and iMplementation of a pan-European instrumenT for radioecology (2013- 2017); www.comet-radioecology.org) project commenced; COMET will build upon the work initiated under STAR. The Radioecology Exchange has therefore become the web resource for activities from both projects which will ultimately be maintained by the European Radioecology Alliance (ALLIANCE; www.er-alliance.org). The Radioecology Exchange is intended to become a ‘gateway’ for information related to European (and wider) radioecological research

Hi-MC: a novel method for high-throughput mitochondrial haplogroup classification

Effective approaches for assessing mitochondrial DNA (mtDNA) variation are important to multiple scientific disciplines. Mitochondrial haplogroups characterize branch points in the phylogeny of mtDNA. Several tools exist for mitochondrial haplogroup classification. However, most require full or partial mtDNA sequence which is often cost prohibitive for studies with large sample sizes. The purpose of this study was to develop Hi-MC, a high-throughput method for mitochondrial haplogroup classification that is cost effective and applicable to large sample sizes making mitochondrial analysis more accessible in genetic studies. Using rigorous selection criteria, we defined and validated a custom panel of mtDNA single nucleotide polymorphisms that allows for accurate classification of European, African, and Native American mitochondrial haplogroups at broad resolution with minimal genotyping and cost. We demonstrate that Hi-MC performs well in samples of European, African, and Native American ancestries, and that Hi-MC performs comparably to a commonly used classifier. Implementation as a software package in R enables users to download and run the program locally, grants greater flexibility in the number of samples that can be run, and allows for easy expansion in future revisions. Hi-MC is available in the CRAN repository and the source code is freely available at https://github.com/vserch/himc

Exposing the myths of household water insecurity in the global north: A critical review

Safe and secure water is a cornerstone of modern life in the global North. This article critically examines a set of prevalent myths about household water in high-income countries, with a focus on Canada and the United States. Taking a relational approach, we argue that household water insecurity is a product of institutionalized structures and power, manifests unevenly through space and time, and is reproduced in places we tend to assume are the most water-secure in the world. We first briefly introduce “modern water” and the modern infrastructural ideal, a highly influential set of ideas that have shaped household water provision and infrastructure development over the past two centuries. Against this backdrop, we consolidate evidence to disrupt a set of narratives about water in high-income countries: the notion that water access is universal, clean, affordable, trustworthy, and uniformly or equitably governed. We identify five thematic areas of future research to delineate an agenda for advancing scholarship and action—including challenges of legal and regulatory regimes, the housing-water nexus, water affordability, and water quality and contamination. Data gaps underpin the experiences of household water insecurity. Taken together, our review of water security for households in high-income countries provides a conceptual map to direct critical research in this area for the coming years. This article is categorized under: Human Water \u3e Human Water