Table of Contents
The Issue in Brief
Discrimination and Medical Mistrust in a Racially and Ethnically Diverse Sample of California Adults
Mohsen Bazargan and colleagues
Background Medical mistrust is a major barrier to a strong patient-clinician relationship. For racial/ethnic minorities, medical mistrust may be rooted in patients' past experience of discrimination. Understanding the mechanisms of these racial differences may lead to better optimization of therapeutic effectiveness and decreased patient mistrust.
What This Study Found Researchers at the Charles R. Drew University in Los Angeles analyzed data from more than 2,300 White, Hispanic, and non-Hispanic Black adults who asked to report on perceived discrimination due to race, ethnicity, language, income, and insurance status or type. Black and Hispanic adults reported higher rates of discrimination across the board, including income and insurance-based discrimination. Black and Hispanic adults reported higher rates of discrimination, including income and insurance-based discrimination. In addition, 20% and 10% of Black and Latino adults stated that they could not get health care services they needed because of racial/ethnic or language discrimination, respectively. The analysis also found a link between having a consistent primary care physician and overall medical trust. Adults who did not have a usual source of primary care were much more likely to report mistrust of healthcare providers.
Implications
- The research team discusses the link between medical mistrust, racial and ethnic discrimination in health care, and roots in institutionalized racism, declaring that "resolving mistrust requires addressing systemic bias and prejudice in the medical system," echoing recent sentiments expressed by the American Medical Association.
Elizabeth H. Golembiewski and colleagues
Background Patients are sometimes asked to share their personal health information for research purposes. Informed consent and trust are critical components in a patient's decision to participate in research. Researchers at the University of Florida conducted a three-arm randomized controlled trial to compare the effects on patient experiences of three electronic consent (e-consent) designs that asked them to share PHI for research purposes. Participants were randomized to a standard e-consent form (standard); an e-consent that contained standard information plus hyperlinks to additional interactive details (interactive); or an e-consent that contained standard information, interactive hyperlinks, and factual messages about data protections and researcher training (trust-enhanced).
What This Study Found Researchers found no differences in preferences at one-week follow up. However, after six months, participants expressed the most satisfaction and subjective understanding with the trust-enhanced e-consent.
Implications
- Research institutions should consider developing and further validating e-consents that deliver information interactively, beyond that which is required by federal regulations, including facts that may enhance patient-informed consent and trust in research.
Diagnostic Agreement Between Telemedicine on Social Networks and Teledermatology Centers
Alexandre Malmartel and colleagues
Background At the start of the pandemic, many doctors on the front lines turned to Twitter and other social media platforms to find guidance and solace directly from their peers. In early 2020, information on COVID-19 had yet to be studied and published in peer-reviewed journals or printed in medical textbooks. Since then, social media has been characterized as both a boon to medical communities seeking real time information and a major driver of misinformation on the virus and its spread. A new study from researchers at the University of Paris provides support for social media as a potentially useful tool in the doctor's diagnostic toolkit and a way for general practitioners with questions to connect to specialists who may have the answers. In France, some general practitioners have turned to social media for help diagnosing common dermatological conditions. They post a deidentified photo of a skin condition to Twitter or MedPics, a private social networking site for doctors, and other clinicians can respond with their diagnosis. In a retrospective observational study, researchers compared the accuracy of using social media to crowdsource a dermatological diagnosis to the accuracy of asking a dermatologist using more traditional telemedicine methods.
What This Study Found Researchers found that diagnoses suggested by doctors on social media generally agreed with teledermatology results, and diagnoses were even more strongly aligned when dermatologists were active in the crowdsourced response. When the images posted to social media were reviewed by an expert committee of dermatologists, the researcher found that primary diagnoses from social media were accurate about 60% of the time, whereas teledermatology consultations were correct about 55% of the time, with no significant difference between the two studied methods.
Implications
- These results suggest that social media can be as useful as teledermatology services for doctors when diagnosing common and minor dermatological conditions, but consultation with an expert dermatologist may still be necessary.
- The authors acknowledge that social media is less secure than standard medical communications technologies and that Twitter and other public platforms do not take the same measures to protect patients' privacy.
Victor Novack and colleagues
Background Harmful medical practices, like inappropriate prescribing of opioids and racial and income-based discrimination in clinical settings, can vary across medical practices and individuals. Patients may find that even common primary care health services, like getting a chest x-rays or a referral to a heart or lung specialist, can differ widely depending on your doctor or clinic location. These variations in medical practice can have serious consequences for the quality, equity and cost of one's health care; however, it�s unclear whether these disparities can be attributed to individual differences, from one doctor to another or to changes in your doctor�s individual practice over time, perhaps in response to shifts in clinical guidelines or advancements in diagnostic technologists. Is it person-to-person variation or variation over time?
What This Study Found A group of Israeli researchers sought to answer this question in a retrospective cohort study using a decade of data from the largest health care provider in southern Israel. This study shows variations between physicians' practice patterns to be significantly more pronounced than variations within an individual physician�s practice patterns over a decade. Researchers assessed the medical practice patterns of 251 primary care physicians, including their rates of imaging tests, cardiac tests, laboratory tests, and specialist visits. After adjusting for different patient and clinic characteristics, practice pattern variations remain high, while individual physicians' patterns over time appear stable.
Implications
- The authors propose that medical practitioners' personal behavioral characteristics might help explain variations across practice patterns.
Pregnancy Medicaid Improvements in a Nonexpansion State After the Affordable Care Act
Jonas J. Swartz and colleagues
Background North Carolina did not expand Medicaid eligibility under the Affordable Care Act, which continued to put many low income women at risk for losing health care coverage postpartum. The state did comply with ACA standards for simplifying Medicaid enrollment, automating the process and removing a stringent and often cumbersome financial assessment process.
What This Study Found Analysis from researchers at Duke University found that these reforms enabled more low-income women to qualify for full Medicaid and reduced the number of women who instead qualified for more limited benefits under the state�s Medicaid for Pregnant Women program. Researchers examined Medicaid claims and vital statistics in North Carolina from 2011 to 2017 and determined that, after changing the full Medicaid enrollment process in 2013 to adhere to the ACA standards, enrollment in full Medicaid during pregnancy doubled and Medicaid for Pregnant Women fell. Full Medicaid does not expire after 60 days and allows women access to crucial preventative health services that include primary care and contraception.
Implications
- Since full Medicaid does not expire after 60 days, it allows women access to crucial preventative health services that include primary care and contraception.
Decreasing Use of Primary Care: A Repeated Cross-Sectional Study of MEPS 2007-2017
Michael E. Johansen and colleague
Background Despite seeing gains in insurance coverage for preventive health services under the Affordable Care Act, the US has seen a declining rate of primary care visits over the past fifteen years. Are fewer individuals seeing primary care doctors.
What This Study Found The authors of this study compared two factors that contribute to that decline to determine whether it was the number of primary care patients or the frequency of their clinical visits that contributed most to the overall decline. Over a fifteen year period from 2002 to 2017, both the number of unique patients seeing PCPs and the number of visits per patient declined. At the start of their analysis in 2002, most Americans saw a primary care physician about 4.3 times in a two-year span. By the end of the study in 2016, frequency of contact dropped to about 3.7 visits. Additionally, the total number of unique patients who had contact with a primary care physician decreased by 2.5% over 15 years and declined across all age groups at varying rates. Applying the rates to adjusted population estimates, the authors conclude that less frequent visits by the average American makes up a larger proportion of the primary care decline compared to the number of primary care patients overall.
Henk Schers and colleagues
Background Family physicians play a central role in providing the first point of access for health care in the Dutch health system. Researchers studied the changes in presented health problems and the demand for primary care during the initial COVID-19 crisis in Nijmegen, a city in the Netherlands. They analyzed data from 25 family physicians and more than 26,000 patients in and around the city. Specifically, researchers examined the most prominent symptoms of COVID-19 including COVID-19 itself as a reason for the family practitioner visit, comparing February through May of 2019 with 2020.
What This Study Found In March of 2020 more people presented with respiratory tract symptoms than in March of 2019. COVID-19 became the most common respiratory tract-related reason for contacting a family physician. However, from April to May 2020, presented symptoms dropped to levels lower than in 2019. Due to the pandemic, the demand for primary care changed rapidly. Acute and chronic health problems, and prevention visits, decreased, while mental health visits did not change.
Implications
- Study findings stress the importance of securing care for all health problems in a primary care's preparations for a major epidemic and to avoid the collateral damage of a health system's single-minded focus on an epidemic.
Samuel Y. S. Wong and colleagues
Background Despite having some of the densest living spaces and the highest number of international visitors, Hong Kong, Singapore, and Beijing have utilized their respective primary health care systems to keep their COVID-19 cases and deaths relatively low.
What This Study Found Researchers studied the primary health care systems in the three cities to identify features of each system that other cities can use as examples to prepare for and prevent deaths in future health crises. Wong et al write that all three cities have made use of primary care in performing public health surveillance and primary care functions
Implications
- Primary care is an indispensable part of any health system and can play an important role in addressing future infectious disease outbreaks when it is supported, engaged, and integrated with other parts of a health system.
The Potential for Cloth Masks to Protect Health Care Clinicians From SARS-CoV-2: A Rapid Review
Cleveland Piggott and colleagues
Background The coronavirus disease 2019 (COVID-19) pandemic has led at times to a scarcity of personal protective equipment, including medical masks, for health care clinicians, especially in primary care settings. The objective of this review was to summarize current evidence regarding the use of cloth masks to prevent respiratory viral infections, such as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), among health care clinicians.
What This Study Found A rapid, evidence-based review summarizes the effectiveness of cloth masks in protecting health care clinicians from respiratory viral infections, such as COVID-19. Nine studies were included in the review, and all but one were conducted prior to the COVID-19 pandemic. The only randomized trial of cloth face masks published at the time of this review compared the infection rates of influenza-like illness among groups of health care professionals who wore cloth masks, medical masks, or inconsistent mask use in the hospital setting. That study reported wide-ranging confidence intervals when comparing groups, but overall, they conclude that cloth mask use was associated with significantly higher viral infections than exclusive use of medical masks. A majority of studies were conducted in laboratory settings and evaluated either cloth face mask fit and airflow when compared to other kinds of mask or the filtration abilities of cloth material and masks. All filtration studies tested aerosolized particles including noncoronavirus, bacteria, and simulated biologic particles, and results were highly variable but suggested some level of participle filtration. Notably, available filtration studies did not specifically test COVID-19 transmission or respiratory droplet transmission. The lab studies all conclude that cloth masks provided an inferior fit and were less effective at filtering viral particles compared to standard medical or N95 masks.
Implications
- Conclusions of this qualitative review align with current Center for Disease Control and Prevention guidelines that recommend use of an N95 respirator for care of patients with COVID-19. The authors also recommend that for health care professionals without access to medical masks, a cloth mask should be paired with the plastic face shield, with frequent cloth mask changes to reduce the risk of moisture retention.
Krys E. Foster and colleagues
Members of the Society of Teachers of Family Medicine Minority and Multicultural Health Collaborative write an open letter to their white colleagues, as reflected in this essay.
Authors discuss their experiences of being educated in unbalanced and biased academic systems, including medical schools. They also share how they have had to carry disproportionately higher financial debt due to student loans. And while physicians of color produce essential research highlighting gaps in care for underserved communities--and tools to address those gaps--they are undervalued, underpaid, denied career advancement, and experience daily micro- and macro-aggressions, according to the authors. As medical doctors who are also people of color, they write that they have had to bear the exhaustive burden of a minority tax, including assuming the responsibility of explaining and then fixing racism and associated inequities of racism in medicine while also balancing the complexities of "white fragility."
Implications
- Authors provide a list of specific actions that their white counterparts can follow to support and elevate the voices of all people of color to break down structural and systemic policies and practices that enforce a culture of racism, inequity, and bias.
What Are You? A Biracial Physician on Nuanced Racism
Emma Lo
Emma Lo, M.D., Assistant Professor of Psychiatry at Yale University School of Medicine, writes a first-person narrative of how she, as a biracial, female resident and early-career psychiatrist, has experienced marginalizing incidents in her practice.
Lo draws attention to the oversimplified categories that fail to consider racial nuances and the resulting culture that excludes and devalues biracial or multiracial health care clinicians. She writes about the emotions she feels in interacting with her colleagues who do nothing to stop the perpetuation of patients' racist views; her frustration about her inability to speak out against and confront the microaggressions she experiences for fear of awkwardness; and shame for her own perceived propagation of racist viewpoints.
Implications
- Lo hopes that her essay illuminates the ambiguity necessary in dialogues about race and enriches literature about racism in medicine.