Gender and Ethnicity Bias in Medicine: A Text Analysis of 1.8 Million Critical Care Records

Gender and ethnicity biases are pervasive across many societal domains including politics, employment, and medicine. Such biases will facilitate inequalities until they are revealed and mitigated at scale. To this end, over 1.8 million records from a large US hospital were evaluated with natural language processing techniques in search of gender and ethnicity bias indicators. Consistent with non-linguistic evidence of bias in medicine, physicians often focused on the emotions of female compared to male patients and focused more on the scientific diagnoses of male compared to female patients. Physicians reported on fewer emotions for Black patients versus White patients and physicians demonstrated the greatest need to work through diagnoses for Black women compared to other patients. This work provides evidence of gender and ethnicity biases in medicine as communicated by physicians in the field and requires the critical examination of institutions that perpetuate bias in social systems.

Physician Attitudes and Self-reported Practices Toward Prostate Cancer Screening in Black and White Men

Background and Objectives: Updated 2018 prostate cancer screening guidelines recommend informed decision-making discussions, which should include education on prostate cancer’s disproportionate impact on Black men. It is unknown whether academic family physicians follow these guidelines. Methods: Family physicians were surveyed as part of the 2020 Council of Academic Family Medicine Educational Research Alliance (CERA) survey. We used χ2 to compare physicians’ knowledge and screening practices stratified by physician age, gender, and percentage of Black patients in patient panel. We calculated logistic regressions predicting shared decision-making conversations, barriers to shared decision-making, inclusion of race in prostate cancer screening approach, and prostate-specific antigen (PSA) testing adjusted for physician age, gender, and percentage of Black patients. Results: Physicians reported engaging in shared decision-making for prostate cancer screening in half of eligible men. Only 29.2% of physicians reported routinely informing Black men of their increased prostate cancer risk. In logistic regressions, physician gender (female) and fewer Black patients in panel (<25%) were associated with lower frequency of shared decision-making with Black patients. Physician age (<40 years) was associated with not discussing race during screening discussions (OR 2.24, 95% CI 1.55–3.23). Conclusions: Most academic family physicians do not appropriately inform Black men of increased prostate cancer risk, with younger physicians less likely to discuss race than older physicians. Female physicians, and physicians who see fewer Black patients, are less likely to have shared decision-making conversations with Black patients. This suggests educational efforts for these groups are needed to address health disparities in prostate cancer.

Racial Disparities in Neutrophil Counts Among Patients with Metastatic Breast Cancer during Treatment with CDK4/6 Inhibitors

Purpose: The three CDK4/6 inhibitors (CDK4/6i) approved for use in HR-positive/HER2-negative metastatic breast cancer (MBC), palbociclib, ribociclib, and abemaciclib, are generally well tolerated but their most common toxicity is neutropenia. Within the general population, neutropenia has been shown to be more common in individuals of African descent. The landmark CDK4/6i trials in MBC lacked racial diversity in their patient populations. We aimed to assess the toxicity profiles of CDK4/6i in a racially diverse population.Methods: We conducted a retrospective study at Montefiore Medical Center in patients with HR-positive/HER2-negative MBC prescribed CDK4/6i as first or subsequent lines of therapy between January 2015 and April 2020. Baseline characteristics and laboratory data at various treatment timepoints were collected. Results: A total of 182 patients were included in the final analysis. Baseline absolute neutrophil count (ANC) was lower in the Black vs. Non-Black cohort (p=0.001) but the change in ANC from baseline (Delta-ANC) was smaller in the Black vs. Non-Black cohort and the ANC at different treatment timepoints was similar between groups. There was no difference in the rate of infection or number of dose delays or reductions between Black and Non-Black cohorts. Conclusion: We analyzed toxicity profiles of 182 patients with HR-positive/HER2-negative MBC treated with CDK4/6i. Our population included 46% Black patients, who were found to have a lower baseline ANC but no increase in complications. Despite the lower baseline ANC seen in our Black cohort prior to starting CDK4/6i, treatment toxicities were similar between racial groups.

Inequities in Chlamydia trachomatis Screening Between Black and White Adolescents in a Large Pediatric Primary Care Network, 2015–2019

Objectives. To identify associations between patient race and annual chlamydia screening among adolescent females. Methods. We performed a retrospective cohort study of females aged 15 to 19 years in a 31-clinic pediatric primary care network in Pennsylvania and New Jersey from 2015 through 2019. Using mixed-effect logistic regressions, we estimated associations between annual chlamydia screening and patient (race/ethnicity, age, previous chlamydia screening and infection, insurance type) and clinic (size, setting) characteristics. We decomposed potential effects of clinician’s implicit racial bias and screening, using covariates measuring the proportion of Black patients in each clinician’s practice. Results. There were 68 935 well visits among 37 817 females, who were 28.8% Black and 25.8% Medicaid insured. The mean annual chlamydia screening rate was 11.1%. Black females had higher odds of screening (adjusted odds ratio [AOR] = 1.67; 95% confidence interval [CI] = 1.51, 1.84) than did White females. In the clinician characteristics model, individual clinicians were more likely to screen their Black versus non-Black patients (AOR = 1.88; 95% CI = 1.65, 2.15). Conclusions. Racial bias may affect screening practices and should be addressed in future interventions, given the critical need to increase population-level chlamydia screening.(Am J Public Health. 2022;112(1):135–143. https://doi.org/10.2105/AJPH.2021.306498 )

Disparities in Offered Anxiety Treatments Among Minorities

Purpose The primary purpose of this article was to determine if race and ethnicity played a role in if primary care physicians offered anxiety treatment in office visits by adult patients who were diagnosed with an anxiety disorder(s). Methods This study pooled data from the 2011 to 2018 National Ambulatory Medical Care Survey (NAMCS) that included adult patients with an anxiety disorder and the type of treatment offered to them. Logistic regressions were performed to examine the odds of offered anxiety treatment in office visits by non-Hispanic Black, Hispanic, and other race/ethnicity patients compared to office visits by non-Hispanic White patients. Results Physicians offered anxiety treatment in more than half of office visits where the patient was diagnosed with an anxiety disorder. Providers offered counseling or talk therapy in less than 13% of all office visits. Office visits by non-Hispanic Black patients had half the odds of being offered counseling/talk therapy ( P = .068) compared to those by non-Hispanic White patients. Conclusions These findings suggest that statistically significant differences in the offering of any anxiety treatments in office visits to minorities compared to non-Hispanic White patients do not exist; however, there are still differences in the rates of counseling/talk therapy offered in office visits by minorities versus non-minorities. Future studies may want to examine reasons for lower rates of counseling/talk therapy offered to minority and majority patients and the specific pharmacological or therapeutic treatments offered to different races.

Impact of Race, Ethnicity, and Socioeconomic Status on Nasopharyngeal Carcinoma Disease-Specific and Conditional Survival

Introduction Race, ethnicity, and socioeconomic status (SES) are complex, interconnected social determinants of health outcomes. This study uses multivariable analysis on a combination of large national datasets to examine the effects of these factors on 5-year disease-specific survival (DSS) and conditional DSS (CDSS) for nasopharyngeal carcinoma (NPC). Methods A retrospective study of adults with NPC between 2000 and 2017 from the Surveillance, Epidemiology, End Results (SEER) registry was performed, using the National Cancer Institute Yost Index, a census tract–level composite score of SES to categorize patients. Kaplan–Meier analysis and Cox's regression for DSS and CDSS were stratified by SES. Logistic regression was conducted to identify risk factors for advanced cancer stage at time of diagnosis and receiving multimodal therapy. Results Our analysis included 5,632 patients. DSS was significantly associated with race and SES (p < 0.01). Asian/Pacific Islander patients exhibited increased survival when controlling for other variables (hazard ratio [HR] = 0.73, p < 0.01). Although Black patients were more likely to be diagnosed with advanced disease (Black odds ratio [OR] = 1.47, p < 0.01), Black patients were also less likely to receive multimodal therapy; however, this relationship lost statistical significance once SES was incorporated into the multivariable analysis. DSS was decreased among the lowest (first) and middle (second) tertiles of SES (first HR = 1.34, p < 0.01; second HR = 1.20, p < 0.01) compared with the highest (third). Conclusion Our results indicate that race, ethnicity, and SES significantly affect survival, stage at diagnosis, and treatment of NPC. An interplay of tumor biology and inequalities in access to care likely drives these disparities.

What Do Placebo and Nocebo Effects Have to Do With Health Equity? The Hidden Toll of Nocebo Effects on Racial and Ethnic Minority Patients in Clinical Care

A placebo effect is a positive clinical response to non-specific elements of treatment with a sham or inert replica of a drug, device, or surgical intervention. There is considerable evidence that placebo effects are driven by expectation of benefit from the intervention. Expectation is shaped by a patient’s past experience, observations of the experience of others, and written, verbal, or non-verbal information communicated during treatment. Not surprisingly, expectation in the clinical setting is strongly influenced by the attitude, affect, and communication style of the healthcare provider. While positive expectations can produce beneficial effects, negative information and experiences can lead to negative expectations, and consequently negative or nocebo effects. Key components identified and studied in the placebo and nocebo literature intersect with factors identified as barriers to quality care in the clinical setting for Black patients and other patients of color, including poor patient-clinician communication, medical mistrust, and perceived discrimination. Thus, in the context of discrimination and bias, the absence of placebo and presence of nocebo-generating influences in clinical settings could potentially reinforce racial and ethnic inequities in clinical outcomes and care. Healthcare inequities have consequences that ripple through the medical system, strengthening adverse short- and long-term outcomes. Here, we examine the potential for the presence of nocebo effects and absence of placebo effects to play a role in contributing to negative outcomes related to unequal treatment in the clinical encounter.