Showing papers by "Marshall H. Chin published in 2022"

Eliminating Explicit and Implicit Biases in Health Care: Evidence and Research Needs

Abstract: Health care providers hold negative explicit and implicit biases against marginalized groups of people such as racial and ethnic minoritized populations. These biases permeate the health care system and affect patients via patient–clinician communication, clinical decision making, and institutionalized practices. Addressing bias remains a fundamental professional responsibility of those accountable for the health and wellness of our populations. Current interventions include instruction on the existence and harmful role of bias in perpetuating health disparities, as well as skills training for the management of bias. These interventions can raise awareness of provider bias and engage health care providers in establishing egalitarian goals for care delivery, but these changes are not sustained, and the interventions have not demonstrated change in behavior in the clinical or learning environment. Unfortunately, the efficacy of these interventions may be hampered by health care providers’ work and learning environments, which are rife with discriminatory practices that sustain the very biases US health care professions are seeking to diminish. We offer a conceptual model demonstrating that provider-level implicit bias interventions should be accompanied by interventions that systemically change structures inside and outside the health care system if the country is to succeed in influencing biases and reducing health inequities.

Critical Theory, Culture Change, and Achieving Health Equity in Health Care Settings

Abstract: Achieving optimal health for all requires confronting the complex legacies of colonialism and white supremacy embedded in all institutions, including health care institutions. As a result, health care organizations committed to health equity must build the capacity of their staff to recognize the contemporary manifestations of these legacies within the organization and to act to eliminate them. In a culture of equity, all employees—individually and collectively—identify and reflect on the organizational dynamics that reproduce health inequities and engage in activities to transform them. The authors describe 5 interconnected change strategies that their medical center uses to build a culture of equity. First, the medical center deliberately grounds diversity, equity, and inclusion efforts (DEI) in critical theory, aiming to illuminate social structures through critical analysis of power relations. Second, its training goes beyond cultural competency and humility to include critical consciousness, which includes the ability to critically analyze conditions in the organizational and broader societal contexts that produce health inequities and act to transform them. Third, it works to strengthen relationships so they can be change vehicles. Fourth, it empowers an implementation team that models a culture of equity. Finally, it aligns equity-focused culture transformation with equity-focused operations transformation to support transformative praxis. These 5 strategies are not a panacea. However, emerging processes and outcomes at the medical center indicate that they may reduce the likelihood of ahistorical and power-blind approaches to equity initiatives and provide employees with some of the critical missing knowledge and skills they need to address the root causes of health inequity.

Standup comedy principles and the personal monologue to explore interpersonal bias: experiential learning in a health disparities course

Abstract: Interpersonal biases between clinicians and patients contribute to disparities in health care and outcomes by race, ethnicity, and socioeconomic status. We used standup comedy principles and exercises to help medical students recognize how others perceive them and how they perceive others, and engage in difficult discussions around implicit biases and interpersonal racism.90 min Zoom workshop with 40 first-year medical students in urban medical school. Intervention consisted of three exercises: Naming icebreaker, Rant and Rave (communicate strong perspective clearly), and Personal Monologue about how others perceive you and how you perceive yourself. Discussion debriefed the personal monologue exercise. Likert scale questions on post-session survey evaluated workshop overall, whether workshop increased skills, and safety of learning environment. Open-ended questions included what trainees liked about the module, what could be improved, and what impact the module had on them?Seventeen (42.5%) students responded to survey. Six respondents identified as white, 4 as Asian, 1 as Black, 1 as multiracial, and 5 did not identify. Seventy-six percent rated the module as "very good" or "excellent", and 94% would recommend the module to others. Most respondents reported the workshop helped them become better listeners (75%) and more observant (82%). Eighty-three percent reported the training could help them take better care of patients with lived experiences different than their own. All respondents believed the learning environment was safe, and 94% reported that instructors created an atmosphere in which they could take risks. Thirty-six percent felt stressed. Students reported the workshop helped them recognize their own identities, others' perceptions, and bidirectional biases, and inspired them to strive for more accurate, authentic interactions with patients.Standup comedy principles show promise for engaging students in meaningful, safe discussions about perceptions and interpersonal biases rooted in their own personal experiences and those of their classmates.

Health Equity for Individuals With Intellectual and Developmental Disabilities.

Abstract: This Viewpoint discusses 3 types of systemic health inequity experienced by individuals with intellectual and developmental disabilities—stigma, exclusion, and devaluation of worth; underrepresentation in population epidemiology and research; and inadequate access to care and social services—and suggests potential approaches to ameliorating inequities in each of these areas.

Standup comedy principles and the personal monologue to explore interpersonal bias: experiential learning in a health disparities course

Abstract: Interpersonal biases between clinicians and patients contribute to disparities in health care and outcomes by race, ethnicity, and socioeconomic status. We used standup comedy principles and exercises to help medical students recognize how others perceive them and how they perceive others, and engage in difficult discussions around implicit biases and interpersonal racism.90 min Zoom workshop with 40 first-year medical students in urban medical school. Intervention consisted of three exercises: Naming icebreaker, Rant and Rave (communicate strong perspective clearly), and Personal Monologue about how others perceive you and how you perceive yourself. Discussion debriefed the personal monologue exercise. Likert scale questions on post-session survey evaluated workshop overall, whether workshop increased skills, and safety of learning environment. Open-ended questions included what trainees liked about the module, what could be improved, and what impact the module had on them?Seventeen (42.5%) students responded to survey. Six respondents identified as white, 4 as Asian, 1 as Black, 1 as multiracial, and 5 did not identify. Seventy-six percent rated the module as "very good" or "excellent", and 94% would recommend the module to others. Most respondents reported the workshop helped them become better listeners (75%) and more observant (82%). Eighty-three percent reported the training could help them take better care of patients with lived experiences different than their own. All respondents believed the learning environment was safe, and 94% reported that instructors created an atmosphere in which they could take risks. Thirty-six percent felt stressed. Students reported the workshop helped them recognize their own identities, others' perceptions, and bidirectional biases, and inspired them to strive for more accurate, authentic interactions with patients.Standup comedy principles show promise for engaging students in meaningful, safe discussions about perceptions and interpersonal biases rooted in their own personal experiences and those of their classmates.

Improvisational and Standup Comedy, Graphic Medicine, and Theatre of the Oppressed to Teach Advancing Health Equity

Abstract: Ninety-minute virtual workshops that used improvisational comedy, standup comedy, graphic medicine, and Theatre of the Oppressed were implemented in 2020 within a required health equity course at the University of Chicago Pritzker School of Medicine to train 90 first-year medical students in advancing health equity. Learning objectives were to (1) deepen understanding of diverse human experiences by developing relationship skills, such as empathy, active listening, engagement, and observation; (2) recognize how diverse patients perceive students and how students perceive them to gain insight into one’s identity and how intersectional systems of oppression can stigmatize and marginalize different identities; and (3) engage in free, frank, fearless, and safe conversations about structural racism, colonialism, White and other social privileges, and systemic factors that lead to health inequities. With a 61% (109/180 [90 students × 2 workshops per student]) survey response rate, 72% of respondents thought workshops were very good or excellent, and 83% agreed or strongly agreed they would recommend workshops to others. Key recommendations are to (1) incorporate experiential storytelling and discussion; (2) define clear learning goals for each workshop, map exercises to these goals, and explain their relevance to students; and (3) create a safe, courageous, brave space for exploration and discussion. For health equity, transformation happens as students share their perspectives of curriculum content from their intersectional identities, experiences, and varied privileges; are challenged by others’ perspectives; and attempt to understand how others can experience the same content differently. The arts create a powerful form of sharing beyond routine conversations or discussions, which is critical for honest dialogue on difficult topics, such as racism, homophobia, and White privilege and other social privileges. Educators should enable students to have the space, time, and courage to share their true perspectives and engage in authentic discussions that may be uncomfortable but transformative.

Early Experience of the Quality Improvement Award Program in Federally Funded Health Centers.

Abstract: OBJECTIVES To describe the Health Resources and Services Administration's Quality Improvement Award (QIA) program, award patterns, and early lessons learned. STUDY SETTING 1413 health centers eligible for QIA from 2014 to 2018. STUDY DESIGN We assessed cumulative QIA funding earned and modified funding excluding payments for per-patient bonuses, electronic health record (EHR) use, patient-centered medical home (PCMH) accreditation, and health information technology. We compared health centers on rural/urban location, PCMH accreditation, EHR reporting, and size. DATA COLLECTION Organizational and quality measures reported in the Uniform Data System, QIA program data. PRINCIPAL FINDINGS Average cumulative funding was higher for health centers that were not rural ($380,387 [± $233,467] vs $303,526 [± $164,272]), had PCMH accreditation ($401,675 [± $218,246] vs $250,784 [± $144,404]), used their EHR for quality reporting ($374,214 (± $222,866) vs $331,150 (± $198,689)), and were large ($435,473 (± $238,193) vs $270,681 (±$114,484) $231,917 (±$97,847) for small and medium centers, respectively). There were similar patterns, with smaller differences, for average modified payments. CONCLUSIONS QIA is an important feasible initiative to introduce value-based payment principles to health centers. Early lessons for program design include announcing award criteria in advance and focusing on a smaller number of priority targets.

Quality of Care for US Adults With Medicaid Insurance and Type 2 Diabetes in Federally Qualified Health Centers Compared With Other Primary Care Settings

Abstract: Objective: The objective of this study was to evaluate indicators of diabetes quality of care for US nonelderly, adult Medicaid enrollees with type 2 diabetes and compare federally qualified health centers (FQHCs) versus non-FQHCs. Research Design and Methods: We analyzed diabetes process measures and acute health services utilization with 2012 US fee-for-service and managed care Medicaid claims in all 50 states and DC. We compared FQHC (N=121,977) to non-FQHC patients (N=700,401) using propensity scores to balance covariates and generalized estimating equation models. Results: Overall, laboratory-based process measures occurred more frequently (range, 65.7%–76.6%) than measures requiring specialty referrals (retinal examinations, 33.3%; diabetes education, 3.4%). Compared with non-FQHC patients, FQHC patients had about 3 percentage point lower rates of each process measure, except for higher rates of diabetes education [relative risk=1.09, 95% confidence interval (CI): 1.03–1.16]. FQHC patients had fewer overall [incident rate ratio (IRR)=0.87, 95% CI: 0.86–0.88] and diabetes-related hospitalizations (IRR=0.79, 95% CI: 0.77–0.81), but more overall (IRR=1.06, 95% CI: 1.05–1.07) and diabetes-related emergency department visits (IRR=1.10, 95% CI: 1.08–1.13). Conclusions: This national analysis identified opportunities to improve diabetes management among Medicaid enrollees with type 2 diabetes, especially for retinal examinations or diabetes education. Overall, we found slightly lower rates of most diabetes care process measures for FQHC patients versus non-FQHC patients. Despite having higher rates of emergency department visits, FQHC patients were significantly less likely to be hospitalized than non-FQHC patients. These findings emphasize the need to identify innovative, effective approaches to improve diabetes care for Medicaid enrollees, especially in FQHC settings.

Supporting Nursing's Critical Role in Advancing Pediatric Health Equity.

Abstract: Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy | Continue JAMA Pediatrics HomeNew OnlineCurrent IssueFor Authors Podcast Publications JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry (1919-1959) JN Learning / CMESubscribeJobsInstitutions / LibrariansReprints & Permissions Terms of Use | Privacy Policy | Accessibility Statement 2023 American Medical Association. All Rights Reserved Search All JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Forum Archive JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry Input Search Term Sign In Individual Sign In Sign inCreate an Account Access through your institution Sign In Purchase Options: Buy this article Rent this article Subscribe to the JAMA Pediatrics journal

Ethical Dimensions of Pricing Transparency.

Abstract: As clinicians, we aim to deliver high-quality care to every patient. We are guided by standards of care that are informed by evidence. In daily practice, however, we might be abruptly led to recontextualize clinical recommendations when patients ask, “How much will this cost?” This is a nuanced question. Patients are typically asking about the price they will pay for services—and, more specifically, the out-of-pocket price—rather than the cost, which has different meanings for different parties but typically refers to expenses incurred to produce and distribute services. Patients may be billed unpredictable amounts for health services we deliver. In the United States, high prices for services have fueled discussions of financial harm and financial toxicity.1,2 In 2018, 2 of 3 adults were worried about affording unexpected bills.3 High health care bills likely contribute to social distrust of health professionals. As researchers, clinicians, and organizations grapple with how to discuss cost-conscious care and what care will cost patients, accurate pricing information is often not reliably, directly, or promptly available.

Parental socialization of mental health in Chinese American families: What parents say and do, and how youth make meaning.

Abstract: Parental mental health socialization is a process by which parents shape how youth develop and maintain beliefs, attitudes, and behaviors regarding mental health and help-seeking behaviors. Although culture shapes parental mental health socialization, few studies have examined specific parental socialization practices regarding mental health and help-seeking, especially as a culturally anchored process. Using a qualitative approach, this study explores youth-reported parental socialization of mental health within Chinese American families by examining focus group data from 69 Chinese American high school and college students. Findings revealed that youth received parental messages that conveyed culturally anchored conceptualizations of mental health that included stigmatized views of mental illness and perceptions of mental distress as not a legitimate problem. Parents responded to youth distress in culturally consonant ways: by encouraging culturally specific coping methods, dismissing or minimizing distress, or responding with silence. Youth engaged in the active interpretation of parental messages through cultural brokering, bridging the gap between their parents' messages and mainstream notions of mental health and help-seeking. Overall, our findings point to the significant role of culture in parental mental health socialization in Chinese American families and the need to integrate culturally specific understandings of mental health into future interventions for Asian American youth.

Development of PRAPARE Social Determinants of Health Clusters and Correlation with Diabetes and Hypertension Outcomes

Abstract: Introduction: PRAPARE is a leading social risk screening tool. No studies yet have simplified the 22 PRAPARE social determinants of health (SDoH) into clusters to analyze associations with chronic disease outcomes. Methods: A federally qualified health center conducted cross-sectional PRAPARE screening on its general adult population. Exploratory and confirmatory factor analyses were used to identify SDoH clusters and construct cluster scores and SDoH total risk scores. Logistic regression assessed relationships between cluster scores and uncontrolled diabetes and/or hypertension. Results: Of the 11,773 adults who answered the survey, 716 had diabetes only, 2,388 had hypertension only, 1,477 had both, and 7,192 had neither. We found 3 composite SDoH clusters (social background, social insecurities, insurance/employment) and 3 standalone clusters (housing status, social isolation, poverty). Among patients with diabetes, those at risk in social background, social insecurities, and insurance/employment were more likely to have uncontrolled diabetes. Among patients with hypertension, those at more risk in social insecurities were more likely to have uncontrolled hypertension. Conclusions: We simplified the 22 PRAPARE SDoH into 3 composite clusters and 3 individual clusters and demonstrated the reliability and validity of PRAPARE. The 3 composite clusters were positively associated with uncontrolled diabetes and/or hypertension.