Diversity in Medicine

Current models used to predict suicide risk fall short for racialized populations including Black, Indigenous, and people of color (BIPOC), new research shows.

Investigators developed two suicide prediction models to examine whether these types of tools are accurate in their predictive abilities, or whether they are flawed.

They found both prediction models failed to identify high-risk BIPOC individuals. In the first model, nearly half of outpatient visits followed by suicide were identified in White patients versus only 7% of visits followed by suicide in BIPOC patients. The second model had a sensitivity of 41% for White patients, but just 3% for Black patients and 7% for American Indian/Alaskan Native patients.

Racial inequities

Suicide risk prediction models have been “developed and validated in several settings” and are now in regular use at the Veterans Health Administration, HealthPartners, and Kaiser Permanente, the authors wrote.

But the performance of suicide risk prediction models, while accurate in the overall population, “remains unexamined” in particular subpopulations, they noted.

“Health records data reflect existing racial and ethnic inequities in health care access, quality, and outcomes; and prediction models using health records data may perpetuate these disparities by presuming that past healthcare patterns accurately reflect actual needs,” Dr. Coley said.

Dr. Coley and associates “wanted to make sure that any suicide prediction model we implemented in clinical care reduced health disparities rather than exacerbated them.”

To investigate, researchers examined all outpatient mental health visits to seven large integrated health care systems by patients 13 years and older (n = 13,980,570 visits by 1,422,534 patients; 64% female, mean age, 42 years). The study spanned from Jan. 1, 2009, to Sept. 30, 2017, with follow-up through Dec. 31, 2017.

In particular, researchers looked at suicides that took place within 90 days following the outpatient visit.

Researchers used two prediction models: logistic regression with LASSO (Least Absolute Shrinkage and Selection Operator) variable selection and random forest technique, a “tree-based method that explores interactions between predictors (including those with race and ethnicity) in estimating probability of an outcome.”

The models considered prespecified interactions between predictors, including prior diagnoses, suicide attempts, and PHQ-9 [Patient Health Questionnaire–9] responses, and race and ethnicity data.

Researchers evaluated performance of the prediction models in the overall validation set and within subgroups defined by race/ethnicity.

The area under the curve measured model discrimination, and sensitivity was estimated for global and race/ethnicity-specific thresholds.
 

‘Unacceptable’ scenario

Within the total population, there were 768 deaths by suicide within 90 days of 3,143 visits. Suicide rates were highest for visits by patients with no recorded race/ethnicity, followed by visits by Asian, White, American Indian/Alaskan Native, Hispanic, and Black patients.

Both models showed “high” AUC sensitivity for White, Hispanic, and Asian patients but “poor” AUC sensitivity for BIPOC and patients without recorded race/ethnicity, the authors reported.

“Implementation of prediction models has to be considered in the broader context of unmet health care needs,” said Dr. Coley.

“In our specific example of suicide prediction, BIPOC populations already face substantial barriers in accessing quality mental health care and, as a result, have poorer outcomes, and using either of the suicide prediction models examined in our study will provide less benefit to already-underserved populations and widen existing care gaps,” a scenario Dr. Coley said is “unacceptable.”

“We must insist that new technologies and methods be used to reduce racial and ethnic inequities in care, not exacerbate them,” she added.
 

Biased algorithms

Commenting on the study, Jonathan Singer, PhD, LCSW, associate professor at Loyola University, Chicago, described it as an “important contribution because it points to a systemic problem and also to the fact that the algorithms we create are biased, created by humans, and humans are biased.”

Although the study focused on the health care system, Dr. Singer believes the findings have implications for individual clinicians.

“If clinicians may be biased against identifying suicide risk in Black and Native American patients, they may attribute suicidal risk to something else. For example, we know that in Black Americans, expressions of intense emotions are oftentimes interpreted as aggression or being threatening, as opposed to indicators of sadness or fear,” noted Dr. Singer, who is also president of the American Academy of Suicidology and was not involved with the study,

“Clinicians who misinterpret these intense emotions are less likely to identify a Black client or patient who is suicidal,” Dr. Singer said.

The research was supported by the Mental Health Research Network from the National Institute of Mental Health. Dr. Coley has reported receiving support through a grant from the Agency for Healthcare Research and Quality. Dr. Singer reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Current models used to predict suicide risk fall short for racialized populations including Black, Indigenous, and people of color (BIPOC), new research shows.

Investigators developed two suicide prediction models to examine whether these types of tools are accurate in their predictive abilities, or whether they are flawed.

They found both prediction models failed to identify high-risk BIPOC individuals. In the first model, nearly half of outpatient visits followed by suicide were identified in White patients versus only 7% of visits followed by suicide in BIPOC patients. The second model had a sensitivity of 41% for White patients, but just 3% for Black patients and 7% for American Indian/Alaskan Native patients.

Racial inequities

Suicide risk prediction models have been “developed and validated in several settings” and are now in regular use at the Veterans Health Administration, HealthPartners, and Kaiser Permanente, the authors wrote.

But the performance of suicide risk prediction models, while accurate in the overall population, “remains unexamined” in particular subpopulations, they noted.

“Health records data reflect existing racial and ethnic inequities in health care access, quality, and outcomes; and prediction models using health records data may perpetuate these disparities by presuming that past healthcare patterns accurately reflect actual needs,” Dr. Coley said.

Dr. Coley and associates “wanted to make sure that any suicide prediction model we implemented in clinical care reduced health disparities rather than exacerbated them.”

To investigate, researchers examined all outpatient mental health visits to seven large integrated health care systems by patients 13 years and older (n = 13,980,570 visits by 1,422,534 patients; 64% female, mean age, 42 years). The study spanned from Jan. 1, 2009, to Sept. 30, 2017, with follow-up through Dec. 31, 2017.

In particular, researchers looked at suicides that took place within 90 days following the outpatient visit.

Researchers used two prediction models: logistic regression with LASSO (Least Absolute Shrinkage and Selection Operator) variable selection and random forest technique, a “tree-based method that explores interactions between predictors (including those with race and ethnicity) in estimating probability of an outcome.”

The models considered prespecified interactions between predictors, including prior diagnoses, suicide attempts, and PHQ-9 [Patient Health Questionnaire–9] responses, and race and ethnicity data.

Researchers evaluated performance of the prediction models in the overall validation set and within subgroups defined by race/ethnicity.

The area under the curve measured model discrimination, and sensitivity was estimated for global and race/ethnicity-specific thresholds.
 

‘Unacceptable’ scenario

Within the total population, there were 768 deaths by suicide within 90 days of 3,143 visits. Suicide rates were highest for visits by patients with no recorded race/ethnicity, followed by visits by Asian, White, American Indian/Alaskan Native, Hispanic, and Black patients.

Both models showed “high” AUC sensitivity for White, Hispanic, and Asian patients but “poor” AUC sensitivity for BIPOC and patients without recorded race/ethnicity, the authors reported.

“Implementation of prediction models has to be considered in the broader context of unmet health care needs,” said Dr. Coley.

“In our specific example of suicide prediction, BIPOC populations already face substantial barriers in accessing quality mental health care and, as a result, have poorer outcomes, and using either of the suicide prediction models examined in our study will provide less benefit to already-underserved populations and widen existing care gaps,” a scenario Dr. Coley said is “unacceptable.”

“We must insist that new technologies and methods be used to reduce racial and ethnic inequities in care, not exacerbate them,” she added.
 

Biased algorithms

Commenting on the study, Jonathan Singer, PhD, LCSW, associate professor at Loyola University, Chicago, described it as an “important contribution because it points to a systemic problem and also to the fact that the algorithms we create are biased, created by humans, and humans are biased.”

Although the study focused on the health care system, Dr. Singer believes the findings have implications for individual clinicians.

“If clinicians may be biased against identifying suicide risk in Black and Native American patients, they may attribute suicidal risk to something else. For example, we know that in Black Americans, expressions of intense emotions are oftentimes interpreted as aggression or being threatening, as opposed to indicators of sadness or fear,” noted Dr. Singer, who is also president of the American Academy of Suicidology and was not involved with the study,

“Clinicians who misinterpret these intense emotions are less likely to identify a Black client or patient who is suicidal,” Dr. Singer said.

The research was supported by the Mental Health Research Network from the National Institute of Mental Health. Dr. Coley has reported receiving support through a grant from the Agency for Healthcare Research and Quality. Dr. Singer reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Current models used to predict suicide risk fall short for racialized populations including Black, Indigenous, and people of color (BIPOC), new research shows.

Investigators developed two suicide prediction models to examine whether these types of tools are accurate in their predictive abilities, or whether they are flawed.

They found both prediction models failed to identify high-risk BIPOC individuals. In the first model, nearly half of outpatient visits followed by suicide were identified in White patients versus only 7% of visits followed by suicide in BIPOC patients. The second model had a sensitivity of 41% for White patients, but just 3% for Black patients and 7% for American Indian/Alaskan Native patients.

Racial inequities

Suicide risk prediction models have been “developed and validated in several settings” and are now in regular use at the Veterans Health Administration, HealthPartners, and Kaiser Permanente, the authors wrote.

But the performance of suicide risk prediction models, while accurate in the overall population, “remains unexamined” in particular subpopulations, they noted.

“Health records data reflect existing racial and ethnic inequities in health care access, quality, and outcomes; and prediction models using health records data may perpetuate these disparities by presuming that past healthcare patterns accurately reflect actual needs,” Dr. Coley said.

Dr. Coley and associates “wanted to make sure that any suicide prediction model we implemented in clinical care reduced health disparities rather than exacerbated them.”

To investigate, researchers examined all outpatient mental health visits to seven large integrated health care systems by patients 13 years and older (n = 13,980,570 visits by 1,422,534 patients; 64% female, mean age, 42 years). The study spanned from Jan. 1, 2009, to Sept. 30, 2017, with follow-up through Dec. 31, 2017.

In particular, researchers looked at suicides that took place within 90 days following the outpatient visit.

Researchers used two prediction models: logistic regression with LASSO (Least Absolute Shrinkage and Selection Operator) variable selection and random forest technique, a “tree-based method that explores interactions between predictors (including those with race and ethnicity) in estimating probability of an outcome.”

The models considered prespecified interactions between predictors, including prior diagnoses, suicide attempts, and PHQ-9 [Patient Health Questionnaire–9] responses, and race and ethnicity data.

Researchers evaluated performance of the prediction models in the overall validation set and within subgroups defined by race/ethnicity.

The area under the curve measured model discrimination, and sensitivity was estimated for global and race/ethnicity-specific thresholds.
 

‘Unacceptable’ scenario

Within the total population, there were 768 deaths by suicide within 90 days of 3,143 visits. Suicide rates were highest for visits by patients with no recorded race/ethnicity, followed by visits by Asian, White, American Indian/Alaskan Native, Hispanic, and Black patients.

Both models showed “high” AUC sensitivity for White, Hispanic, and Asian patients but “poor” AUC sensitivity for BIPOC and patients without recorded race/ethnicity, the authors reported.

“Implementation of prediction models has to be considered in the broader context of unmet health care needs,” said Dr. Coley.

“In our specific example of suicide prediction, BIPOC populations already face substantial barriers in accessing quality mental health care and, as a result, have poorer outcomes, and using either of the suicide prediction models examined in our study will provide less benefit to already-underserved populations and widen existing care gaps,” a scenario Dr. Coley said is “unacceptable.”

“We must insist that new technologies and methods be used to reduce racial and ethnic inequities in care, not exacerbate them,” she added.
 

Biased algorithms

Commenting on the study, Jonathan Singer, PhD, LCSW, associate professor at Loyola University, Chicago, described it as an “important contribution because it points to a systemic problem and also to the fact that the algorithms we create are biased, created by humans, and humans are biased.”

Although the study focused on the health care system, Dr. Singer believes the findings have implications for individual clinicians.

“If clinicians may be biased against identifying suicide risk in Black and Native American patients, they may attribute suicidal risk to something else. For example, we know that in Black Americans, expressions of intense emotions are oftentimes interpreted as aggression or being threatening, as opposed to indicators of sadness or fear,” noted Dr. Singer, who is also president of the American Academy of Suicidology and was not involved with the study,

“Clinicians who misinterpret these intense emotions are less likely to identify a Black client or patient who is suicidal,” Dr. Singer said.

The research was supported by the Mental Health Research Network from the National Institute of Mental Health. Dr. Coley has reported receiving support through a grant from the Agency for Healthcare Research and Quality. Dr. Singer reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

In her welcome video on the opening day at the annual meeting of the Society of General Internal Medicine, meeting chair Rita Lee, MD, said she hoped that this year’s event, though virtual, will allow attendees an opportunity to “regroup, find inspiration, and celebrate the incredible strengths and diverse voices of our community.”

“We are living in an incredibly polarized world,” Dr. Lee said in an interview. “The conference theme of ‘Transforming Values Into Action’ is especially important at this time, as recent events, such as the death of George Floyd and many others, plus the disparities revealed by the COVID-19 pandemic, have brought issues of structural racism and oppression in the United States to the forefront,” she said in the interview.

“Given these circumstances, it is important now, more than ever, for generalists to move our values into action – to effect change at the health system, community, and policy levels – so our patients can achieve optimal health,” Dr. Lee emphasized.

She noted that SGIM’s vision: “A just system of care in which all people can achieve optimal health,” underlies the meeting’s sessions.

Some challenges related to adopting more antiracist training in medical education center on faculty development, Dr. Lee noted. “There are also students who don’t feel that this is part of the role of being a physician. One way to overcome these challenges is by directly linking structural competency to health outcomes for our patients,” she added. “We have evidence that structural racism impacts health and we should make that clear to our educational leaders and faculty to increase buy in. So many of our SGIM members are working on developing curricula for this.”

Two of the meeting’s workshops that addressed racism in medicine and medical education and strategies for change were “Demystifying Structural Competency – How to Develop Antiracist Training in Medical Education,” and “Combating Systemic Racism in the Health Care System – Practical Actions You Can Take Today.” Below are some details about these.
 

Medical education evolves to include structural competency

In the workshop “Demystifying Structural Competency – How to Develop Antiracist Training in Medical Education,” participants used interactive exercises to build structural differentials for patient cases. The workshop was based in part on the experiences of including structural competency in medical education at Albert Einstein College of Medicine, New York, and the University of Pittsburgh.

During the session, participants practiced building a structural differential diagnosis in small groups, and also practiced using a structurally competent version of the 1-minute preceptor to promote structural competency in learners.

“Structural competency represents a shift in medical education towards attention to forces that influence health outcomes at levels above individual clinical interactions and develop a provider’s capacity to recognize and respond to health and illness as downstream effects of social, political and economic structures,” presenter Iman Hassan, MD, of Albert Einstein College of Medicine and Montefiore Health System, both in New York, said in an interview.

“At the same time, structural competency incorporates structural humility, which decentralizes the provider role in addressing structural factors and emphasizes collaboration with patients and communities,” she said in the interview. “Structural competency is a useful antiracism framework because it explicitly engages learners with the broader structural forces that result in health disparities, including structural racism and its downstream effects,” Dr. Hassan explained.

Addressing structural competency is important in medical education because structural and social determinants of health contribute more than half of overall health outcomes, said Dr. Hassan.

A structural competency framework equips learners to identify, discuss, and work with patients to navigate social needs such as lack of health insurance, food, or transportation, that are preventing them from accessing needed health care services, Dr. Hassan noted.

“Importantly, training in structural competency empowers physicians to be agents of change within their clinics, health systems, and communities and to recognize the value of community-led advocacy in promoting health equity,” she said.

Structural competency training also “will also allow them to engage more fully with the body of literature that exists surrounding social determinants of health and health disparities, and the use of approaches such as critical race theory through which to view health care,” she emphasized. “Importantly, understanding of the historical and structural context of medicine allows clinicians to more readily recognize when their own clinical practices, such as use of race-based clinical prediction tools, may perpetuate disparities, and work collectively to eliminate those practices.”
 

Recalibrating calculators for clinical care

Another workshop, “Combating Systemic Racism in the Health Care System – Practical Actions You Can Take Today,” took on the challenge of inherent bias in clinical care caused by various factors, notably medical calculators such as those used to measure kidney function and pulmonary function.

Lamar K. Johnson, MD, of Christiana Care Hospital Partners/Christiana Care Pediatric Hospitalists in Newark, Del., and Celeste Newby, MD, of Tulane University, New Orleans, discussed the inherent biases in some calculators and how to take those biases into account. A stated goal of the workshop was to increase awareness of the origins of medical calculators in order to enhance equity and improve shared decision-making between patients and providers.

Addressing implicit bias in clinical practice is important because such bias has been shown to negatively affect physician behavior and clinical decision making, Dr. Johnson said in an interview.

“These effects can also negatively affect the doctor-patient relationship and lead to poorer health outcomes due to delays in or avoidance of care or avoidance of the health care system, and mistrust, resulting in nonadherence,” Dr. Johnson noted.

“Implicit bias training helps empower medical students and residents to recognize and address bias and advocate for patients. Such training can potentially be beneficial to faculty, too,” Dr. Johnson emphasized in the interview.

“Race is primarily a social, not a biological, construct, and we must be careful when we use it, as its use in the past has been largely inappropriate and not scientifically sound,” he said.

During the session, one of the presenters said removing specific mentions of race from clinical documentation can reduce racial bias in clinical practice.

The presenters also highlighted the estimated glomerular filtration rate (eGFR) which is used to estimate kidney function.

The eGFR “reports higher eGFR values for Blacks based on a faulty hypothesis that Black people have higher muscle mass. This higher estimated value can delay referral for specialist care or transplantation, leading to worse outcomes,” Dr. Johnson explained in the interview.

In response, “Many major institutions have eliminated the race modifier in eGFR, and a joint task force created by the National Kidney Foundation and American Society of Nephrology has recommended against using a race modifier as of March 2021,” Dr. Johnson said.

The presenters had no relevant financial conflicts to disclose.

In her welcome video on the opening day at the annual meeting of the Society of General Internal Medicine, meeting chair Rita Lee, MD, said she hoped that this year’s event, though virtual, will allow attendees an opportunity to “regroup, find inspiration, and celebrate the incredible strengths and diverse voices of our community.”

“We are living in an incredibly polarized world,” Dr. Lee said in an interview. “The conference theme of ‘Transforming Values Into Action’ is especially important at this time, as recent events, such as the death of George Floyd and many others, plus the disparities revealed by the COVID-19 pandemic, have brought issues of structural racism and oppression in the United States to the forefront,” she said in the interview.

“Given these circumstances, it is important now, more than ever, for generalists to move our values into action – to effect change at the health system, community, and policy levels – so our patients can achieve optimal health,” Dr. Lee emphasized.

She noted that SGIM’s vision: “A just system of care in which all people can achieve optimal health,” underlies the meeting’s sessions.

Some challenges related to adopting more antiracist training in medical education center on faculty development, Dr. Lee noted. “There are also students who don’t feel that this is part of the role of being a physician. One way to overcome these challenges is by directly linking structural competency to health outcomes for our patients,” she added. “We have evidence that structural racism impacts health and we should make that clear to our educational leaders and faculty to increase buy in. So many of our SGIM members are working on developing curricula for this.”

Two of the meeting’s workshops that addressed racism in medicine and medical education and strategies for change were “Demystifying Structural Competency – How to Develop Antiracist Training in Medical Education,” and “Combating Systemic Racism in the Health Care System – Practical Actions You Can Take Today.” Below are some details about these.
 

Medical education evolves to include structural competency

In the workshop “Demystifying Structural Competency – How to Develop Antiracist Training in Medical Education,” participants used interactive exercises to build structural differentials for patient cases. The workshop was based in part on the experiences of including structural competency in medical education at Albert Einstein College of Medicine, New York, and the University of Pittsburgh.

During the session, participants practiced building a structural differential diagnosis in small groups, and also practiced using a structurally competent version of the 1-minute preceptor to promote structural competency in learners.

“Structural competency represents a shift in medical education towards attention to forces that influence health outcomes at levels above individual clinical interactions and develop a provider’s capacity to recognize and respond to health and illness as downstream effects of social, political and economic structures,” presenter Iman Hassan, MD, of Albert Einstein College of Medicine and Montefiore Health System, both in New York, said in an interview.

“At the same time, structural competency incorporates structural humility, which decentralizes the provider role in addressing structural factors and emphasizes collaboration with patients and communities,” she said in the interview. “Structural competency is a useful antiracism framework because it explicitly engages learners with the broader structural forces that result in health disparities, including structural racism and its downstream effects,” Dr. Hassan explained.

Addressing structural competency is important in medical education because structural and social determinants of health contribute more than half of overall health outcomes, said Dr. Hassan.

A structural competency framework equips learners to identify, discuss, and work with patients to navigate social needs such as lack of health insurance, food, or transportation, that are preventing them from accessing needed health care services, Dr. Hassan noted.

“Importantly, training in structural competency empowers physicians to be agents of change within their clinics, health systems, and communities and to recognize the value of community-led advocacy in promoting health equity,” she said.

Structural competency training also “will also allow them to engage more fully with the body of literature that exists surrounding social determinants of health and health disparities, and the use of approaches such as critical race theory through which to view health care,” she emphasized. “Importantly, understanding of the historical and structural context of medicine allows clinicians to more readily recognize when their own clinical practices, such as use of race-based clinical prediction tools, may perpetuate disparities, and work collectively to eliminate those practices.”
 

Recalibrating calculators for clinical care

Another workshop, “Combating Systemic Racism in the Health Care System – Practical Actions You Can Take Today,” took on the challenge of inherent bias in clinical care caused by various factors, notably medical calculators such as those used to measure kidney function and pulmonary function.

Lamar K. Johnson, MD, of Christiana Care Hospital Partners/Christiana Care Pediatric Hospitalists in Newark, Del., and Celeste Newby, MD, of Tulane University, New Orleans, discussed the inherent biases in some calculators and how to take those biases into account. A stated goal of the workshop was to increase awareness of the origins of medical calculators in order to enhance equity and improve shared decision-making between patients and providers.

Addressing implicit bias in clinical practice is important because such bias has been shown to negatively affect physician behavior and clinical decision making, Dr. Johnson said in an interview.

“These effects can also negatively affect the doctor-patient relationship and lead to poorer health outcomes due to delays in or avoidance of care or avoidance of the health care system, and mistrust, resulting in nonadherence,” Dr. Johnson noted.

“Implicit bias training helps empower medical students and residents to recognize and address bias and advocate for patients. Such training can potentially be beneficial to faculty, too,” Dr. Johnson emphasized in the interview.

“Race is primarily a social, not a biological, construct, and we must be careful when we use it, as its use in the past has been largely inappropriate and not scientifically sound,” he said.

During the session, one of the presenters said removing specific mentions of race from clinical documentation can reduce racial bias in clinical practice.

The presenters also highlighted the estimated glomerular filtration rate (eGFR) which is used to estimate kidney function.

The eGFR “reports higher eGFR values for Blacks based on a faulty hypothesis that Black people have higher muscle mass. This higher estimated value can delay referral for specialist care or transplantation, leading to worse outcomes,” Dr. Johnson explained in the interview.

In response, “Many major institutions have eliminated the race modifier in eGFR, and a joint task force created by the National Kidney Foundation and American Society of Nephrology has recommended against using a race modifier as of March 2021,” Dr. Johnson said.

The presenters had no relevant financial conflicts to disclose.

In her welcome video on the opening day at the annual meeting of the Society of General Internal Medicine, meeting chair Rita Lee, MD, said she hoped that this year’s event, though virtual, will allow attendees an opportunity to “regroup, find inspiration, and celebrate the incredible strengths and diverse voices of our community.”

“We are living in an incredibly polarized world,” Dr. Lee said in an interview. “The conference theme of ‘Transforming Values Into Action’ is especially important at this time, as recent events, such as the death of George Floyd and many others, plus the disparities revealed by the COVID-19 pandemic, have brought issues of structural racism and oppression in the United States to the forefront,” she said in the interview.

“Given these circumstances, it is important now, more than ever, for generalists to move our values into action – to effect change at the health system, community, and policy levels – so our patients can achieve optimal health,” Dr. Lee emphasized.

She noted that SGIM’s vision: “A just system of care in which all people can achieve optimal health,” underlies the meeting’s sessions.

Some challenges related to adopting more antiracist training in medical education center on faculty development, Dr. Lee noted. “There are also students who don’t feel that this is part of the role of being a physician. One way to overcome these challenges is by directly linking structural competency to health outcomes for our patients,” she added. “We have evidence that structural racism impacts health and we should make that clear to our educational leaders and faculty to increase buy in. So many of our SGIM members are working on developing curricula for this.”

Two of the meeting’s workshops that addressed racism in medicine and medical education and strategies for change were “Demystifying Structural Competency – How to Develop Antiracist Training in Medical Education,” and “Combating Systemic Racism in the Health Care System – Practical Actions You Can Take Today.” Below are some details about these.
 

Medical education evolves to include structural competency

In the workshop “Demystifying Structural Competency – How to Develop Antiracist Training in Medical Education,” participants used interactive exercises to build structural differentials for patient cases. The workshop was based in part on the experiences of including structural competency in medical education at Albert Einstein College of Medicine, New York, and the University of Pittsburgh.

During the session, participants practiced building a structural differential diagnosis in small groups, and also practiced using a structurally competent version of the 1-minute preceptor to promote structural competency in learners.

“Structural competency represents a shift in medical education towards attention to forces that influence health outcomes at levels above individual clinical interactions and develop a provider’s capacity to recognize and respond to health and illness as downstream effects of social, political and economic structures,” presenter Iman Hassan, MD, of Albert Einstein College of Medicine and Montefiore Health System, both in New York, said in an interview.

“At the same time, structural competency incorporates structural humility, which decentralizes the provider role in addressing structural factors and emphasizes collaboration with patients and communities,” she said in the interview. “Structural competency is a useful antiracism framework because it explicitly engages learners with the broader structural forces that result in health disparities, including structural racism and its downstream effects,” Dr. Hassan explained.

Addressing structural competency is important in medical education because structural and social determinants of health contribute more than half of overall health outcomes, said Dr. Hassan.

A structural competency framework equips learners to identify, discuss, and work with patients to navigate social needs such as lack of health insurance, food, or transportation, that are preventing them from accessing needed health care services, Dr. Hassan noted.

“Importantly, training in structural competency empowers physicians to be agents of change within their clinics, health systems, and communities and to recognize the value of community-led advocacy in promoting health equity,” she said.

Structural competency training also “will also allow them to engage more fully with the body of literature that exists surrounding social determinants of health and health disparities, and the use of approaches such as critical race theory through which to view health care,” she emphasized. “Importantly, understanding of the historical and structural context of medicine allows clinicians to more readily recognize when their own clinical practices, such as use of race-based clinical prediction tools, may perpetuate disparities, and work collectively to eliminate those practices.”
 

Recalibrating calculators for clinical care

Another workshop, “Combating Systemic Racism in the Health Care System – Practical Actions You Can Take Today,” took on the challenge of inherent bias in clinical care caused by various factors, notably medical calculators such as those used to measure kidney function and pulmonary function.

Lamar K. Johnson, MD, of Christiana Care Hospital Partners/Christiana Care Pediatric Hospitalists in Newark, Del., and Celeste Newby, MD, of Tulane University, New Orleans, discussed the inherent biases in some calculators and how to take those biases into account. A stated goal of the workshop was to increase awareness of the origins of medical calculators in order to enhance equity and improve shared decision-making between patients and providers.

Addressing implicit bias in clinical practice is important because such bias has been shown to negatively affect physician behavior and clinical decision making, Dr. Johnson said in an interview.

“These effects can also negatively affect the doctor-patient relationship and lead to poorer health outcomes due to delays in or avoidance of care or avoidance of the health care system, and mistrust, resulting in nonadherence,” Dr. Johnson noted.

“Implicit bias training helps empower medical students and residents to recognize and address bias and advocate for patients. Such training can potentially be beneficial to faculty, too,” Dr. Johnson emphasized in the interview.

“Race is primarily a social, not a biological, construct, and we must be careful when we use it, as its use in the past has been largely inappropriate and not scientifically sound,” he said.

During the session, one of the presenters said removing specific mentions of race from clinical documentation can reduce racial bias in clinical practice.

The presenters also highlighted the estimated glomerular filtration rate (eGFR) which is used to estimate kidney function.

The eGFR “reports higher eGFR values for Blacks based on a faulty hypothesis that Black people have higher muscle mass. This higher estimated value can delay referral for specialist care or transplantation, leading to worse outcomes,” Dr. Johnson explained in the interview.

In response, “Many major institutions have eliminated the race modifier in eGFR, and a joint task force created by the National Kidney Foundation and American Society of Nephrology has recommended against using a race modifier as of March 2021,” Dr. Johnson said.

The presenters had no relevant financial conflicts to disclose.

Social and economic disparities are linked to an increased risk for psychosis in Black and Latino communities, new research shows.

Results of a literature review of social and economic disparities in mental illness suggest that “structural racism” contributes to social and environmental conditions that affect psychosis risk.

“Black and Latino people suffer disproportionately from psychosis risk factors, at the neighborhood level and at the individual level, in large part as a result of structural racism,” study investigator Deidre M. Anglin, PhD, associate professor, department of psychology, City College of New York (N.Y.), told reporters attending a press briefing.

The social environment, which, for minorities, involves disadvantage and discrimination, may account for this increased psychosis risk, perhaps even more so than genetics, she said. Structural racism “is a critical public health threat,” Dr. Anglin added.

The findings were presented at the virtual American Psychiatric Association annual meeting and were simultaneously published online May 3 in The American Journal of Psychiatry.
 

Perpetual disadvantage

Dr. Anglin and colleagues examined U.S.-based evidence connecting characteristics of social environments with outcomes across the psychosis continuum – from psychotic experiences to schizophrenia.

Citing numerous studies, the researchers highlighted three key areas that reflect social and environmental conditions that may affect psychosis risk, and that disproportionately affect minorities. These were neighborhood factors, trauma in a U.S. context, and racial disparities during the prenatal and perinatal periods.

The data that were related to neighborhoods revealed “just how much racism has historically structured U.S. neighborhoods in ways that generationally perpetuate disadvantage for racially minoritized communities,” said Dr. Anglin.

“This happens through inequitable access to resources, such as health care, clean air, education, [and] employment, but also in terms of disproportionate exposure to environmental toxins and stressors,” she said.

These neighborhood factors are associated with cumulative stress that may be linked to heightened risk for psychosis, the investigators noted.

U.S. studies show that rates of adverse childhood experiences, such as abuse and emotional and physical neglect, are higher among racial and ethnic minorities.

Police victimization and gun violence disproportionately affect racial minorities and create what the investigators call “a unique type of collective trauma” in the United States. They note that Black men have a 1 in 1,000 chance of being victims of lethal force by police over their lifetimes. By comparison, White men have a 39 in 100,000 chance.

One study of a diverse sample from four large U.S. urban centers showed that those who self-reported different types of police victimization were more likely to report psychotic experiences. Another study showed that greater exposure to gun violence fatalities, regardless of police involvement, was positively associated with psychotic experiences.
 

Obstetric complications

A variety of obstetric complications, including infection, maternal inflammation, and stress, have been associated with increased risk for psychotic disorders in U.S. samples.

“What we saw emerge from the literature is that Black women in the U.S. are at substantially increased risk for many of these obstetrical complications compared to White women, and this is not necessarily explained by socioeconomic status,” said Dr. Anglin.

Neighborhood- and individual-level factors appear to affect the disparity in these outcomes. A recent study revealed that exposure to environmental contaminants such as air pollution is associated with higher rates of preterm birth and low birth weight differentially in Black mothers compared with other mothers, “possibly as a result of an interaction between prenatal stress and contaminants,” the investigators noted.

Research also indicates that Black women are more likely to have lower levels of cortisol during the second trimester of pregnancy compared with women of other racial and ethnic groups. Cortisol is essential for fetal growth. Evidence links lower cortisol levels in later stages of pregnancy with decreased fetal growth in individuals who develop schizophrenia.

Black women have higher levels of certain stress biomarkers, including inflammatory C-reactive protein and adrenocorticotropic hormone, in mid- to late pregnancy, compared with White women of the same socioeconomic status.

Such findings “highlight a complex picture” involving maternal cortisol levels and other stress biomarkers, “potentially leading to poor birth outcomes and subsequent risk for psychotic disorders in adulthood,” the investigators noted.

The researchers call for the dismantling of structural racism and the social policies and norms it shapes. They also recommend changes in health care policy and in the approach to early intervention for psychosis among Black and other racially-minoritized groups.

“Altogether, the current evidence suggests the need to identify, address, and tackle the social determinants deeply ingrained in U.S. society, in tandem with empowering the most marginalized communities,” the researchers wrote.

“We recommend that the field of psychiatry devote considerably more effort to addressing structural racism and social determinants of psychosis in funding priorities, training, and intervention development,” they added.

Dr. Anglin suggests that mental health providers use what she called a “cultural formulation interview” that takes a person’s environmental and social context into consideration. Studies show that incorporating this into clinical practice helps reduce misdiagnosis of mental illness in Black populations, she said.
 

Call to action

Commenting on the findings in an interview, Ned H. Kalin, MD, editor of The American Journal of Psychiatry and professor and chair of the department of psychiatry, University of Wisconsin, Madison, said the study was well done and serves as a “call to action” to address the impact of structural racism on mental health issues and psychiatric diseases.

The article highlights the need for “collecting better data” on structural racism, said Dr. Kalin. “We know it’s a big issue, but we can’t even quantitate it, so we need some fundamental measures to use as a benchmark as we move forward, as we try to make change.”

He noted that racism “is so embedded in one’s experience and in our society that we sort of don’t even think about it as a trauma.”

In psychiatry, for example, trauma is often thought of as a loss or a traumatic event. “We don’t typically think of trauma as an experience that pervades one’s entire life,” but that needs to change, he said. “At the individual level and in the doctor’s office, being sensitive to and aware of these issues is absolutely critical.”

Dr. Anglin and Dr. Kalin have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Social and economic disparities are linked to an increased risk for psychosis in Black and Latino communities, new research shows.

Results of a literature review of social and economic disparities in mental illness suggest that “structural racism” contributes to social and environmental conditions that affect psychosis risk.

“Black and Latino people suffer disproportionately from psychosis risk factors, at the neighborhood level and at the individual level, in large part as a result of structural racism,” study investigator Deidre M. Anglin, PhD, associate professor, department of psychology, City College of New York (N.Y.), told reporters attending a press briefing.

The social environment, which, for minorities, involves disadvantage and discrimination, may account for this increased psychosis risk, perhaps even more so than genetics, she said. Structural racism “is a critical public health threat,” Dr. Anglin added.

The findings were presented at the virtual American Psychiatric Association annual meeting and were simultaneously published online May 3 in The American Journal of Psychiatry.
 

Perpetual disadvantage

Dr. Anglin and colleagues examined U.S.-based evidence connecting characteristics of social environments with outcomes across the psychosis continuum – from psychotic experiences to schizophrenia.

Citing numerous studies, the researchers highlighted three key areas that reflect social and environmental conditions that may affect psychosis risk, and that disproportionately affect minorities. These were neighborhood factors, trauma in a U.S. context, and racial disparities during the prenatal and perinatal periods.

The data that were related to neighborhoods revealed “just how much racism has historically structured U.S. neighborhoods in ways that generationally perpetuate disadvantage for racially minoritized communities,” said Dr. Anglin.

“This happens through inequitable access to resources, such as health care, clean air, education, [and] employment, but also in terms of disproportionate exposure to environmental toxins and stressors,” she said.

These neighborhood factors are associated with cumulative stress that may be linked to heightened risk for psychosis, the investigators noted.

U.S. studies show that rates of adverse childhood experiences, such as abuse and emotional and physical neglect, are higher among racial and ethnic minorities.

Police victimization and gun violence disproportionately affect racial minorities and create what the investigators call “a unique type of collective trauma” in the United States. They note that Black men have a 1 in 1,000 chance of being victims of lethal force by police over their lifetimes. By comparison, White men have a 39 in 100,000 chance.

One study of a diverse sample from four large U.S. urban centers showed that those who self-reported different types of police victimization were more likely to report psychotic experiences. Another study showed that greater exposure to gun violence fatalities, regardless of police involvement, was positively associated with psychotic experiences.
 

Obstetric complications

A variety of obstetric complications, including infection, maternal inflammation, and stress, have been associated with increased risk for psychotic disorders in U.S. samples.

“What we saw emerge from the literature is that Black women in the U.S. are at substantially increased risk for many of these obstetrical complications compared to White women, and this is not necessarily explained by socioeconomic status,” said Dr. Anglin.

Neighborhood- and individual-level factors appear to affect the disparity in these outcomes. A recent study revealed that exposure to environmental contaminants such as air pollution is associated with higher rates of preterm birth and low birth weight differentially in Black mothers compared with other mothers, “possibly as a result of an interaction between prenatal stress and contaminants,” the investigators noted.

Research also indicates that Black women are more likely to have lower levels of cortisol during the second trimester of pregnancy compared with women of other racial and ethnic groups. Cortisol is essential for fetal growth. Evidence links lower cortisol levels in later stages of pregnancy with decreased fetal growth in individuals who develop schizophrenia.

Black women have higher levels of certain stress biomarkers, including inflammatory C-reactive protein and adrenocorticotropic hormone, in mid- to late pregnancy, compared with White women of the same socioeconomic status.

Such findings “highlight a complex picture” involving maternal cortisol levels and other stress biomarkers, “potentially leading to poor birth outcomes and subsequent risk for psychotic disorders in adulthood,” the investigators noted.

The researchers call for the dismantling of structural racism and the social policies and norms it shapes. They also recommend changes in health care policy and in the approach to early intervention for psychosis among Black and other racially-minoritized groups.

“Altogether, the current evidence suggests the need to identify, address, and tackle the social determinants deeply ingrained in U.S. society, in tandem with empowering the most marginalized communities,” the researchers wrote.

“We recommend that the field of psychiatry devote considerably more effort to addressing structural racism and social determinants of psychosis in funding priorities, training, and intervention development,” they added.

Dr. Anglin suggests that mental health providers use what she called a “cultural formulation interview” that takes a person’s environmental and social context into consideration. Studies show that incorporating this into clinical practice helps reduce misdiagnosis of mental illness in Black populations, she said.
 

Call to action

Commenting on the findings in an interview, Ned H. Kalin, MD, editor of The American Journal of Psychiatry and professor and chair of the department of psychiatry, University of Wisconsin, Madison, said the study was well done and serves as a “call to action” to address the impact of structural racism on mental health issues and psychiatric diseases.

The article highlights the need for “collecting better data” on structural racism, said Dr. Kalin. “We know it’s a big issue, but we can’t even quantitate it, so we need some fundamental measures to use as a benchmark as we move forward, as we try to make change.”

He noted that racism “is so embedded in one’s experience and in our society that we sort of don’t even think about it as a trauma.”

In psychiatry, for example, trauma is often thought of as a loss or a traumatic event. “We don’t typically think of trauma as an experience that pervades one’s entire life,” but that needs to change, he said. “At the individual level and in the doctor’s office, being sensitive to and aware of these issues is absolutely critical.”

Dr. Anglin and Dr. Kalin have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Social and economic disparities are linked to an increased risk for psychosis in Black and Latino communities, new research shows.

Results of a literature review of social and economic disparities in mental illness suggest that “structural racism” contributes to social and environmental conditions that affect psychosis risk.

“Black and Latino people suffer disproportionately from psychosis risk factors, at the neighborhood level and at the individual level, in large part as a result of structural racism,” study investigator Deidre M. Anglin, PhD, associate professor, department of psychology, City College of New York (N.Y.), told reporters attending a press briefing.

The social environment, which, for minorities, involves disadvantage and discrimination, may account for this increased psychosis risk, perhaps even more so than genetics, she said. Structural racism “is a critical public health threat,” Dr. Anglin added.

The findings were presented at the virtual American Psychiatric Association annual meeting and were simultaneously published online May 3 in The American Journal of Psychiatry.
 

Perpetual disadvantage

Dr. Anglin and colleagues examined U.S.-based evidence connecting characteristics of social environments with outcomes across the psychosis continuum – from psychotic experiences to schizophrenia.

Citing numerous studies, the researchers highlighted three key areas that reflect social and environmental conditions that may affect psychosis risk, and that disproportionately affect minorities. These were neighborhood factors, trauma in a U.S. context, and racial disparities during the prenatal and perinatal periods.

The data that were related to neighborhoods revealed “just how much racism has historically structured U.S. neighborhoods in ways that generationally perpetuate disadvantage for racially minoritized communities,” said Dr. Anglin.

“This happens through inequitable access to resources, such as health care, clean air, education, [and] employment, but also in terms of disproportionate exposure to environmental toxins and stressors,” she said.

These neighborhood factors are associated with cumulative stress that may be linked to heightened risk for psychosis, the investigators noted.

U.S. studies show that rates of adverse childhood experiences, such as abuse and emotional and physical neglect, are higher among racial and ethnic minorities.

Police victimization and gun violence disproportionately affect racial minorities and create what the investigators call “a unique type of collective trauma” in the United States. They note that Black men have a 1 in 1,000 chance of being victims of lethal force by police over their lifetimes. By comparison, White men have a 39 in 100,000 chance.

One study of a diverse sample from four large U.S. urban centers showed that those who self-reported different types of police victimization were more likely to report psychotic experiences. Another study showed that greater exposure to gun violence fatalities, regardless of police involvement, was positively associated with psychotic experiences.
 

Obstetric complications

A variety of obstetric complications, including infection, maternal inflammation, and stress, have been associated with increased risk for psychotic disorders in U.S. samples.

“What we saw emerge from the literature is that Black women in the U.S. are at substantially increased risk for many of these obstetrical complications compared to White women, and this is not necessarily explained by socioeconomic status,” said Dr. Anglin.

Neighborhood- and individual-level factors appear to affect the disparity in these outcomes. A recent study revealed that exposure to environmental contaminants such as air pollution is associated with higher rates of preterm birth and low birth weight differentially in Black mothers compared with other mothers, “possibly as a result of an interaction between prenatal stress and contaminants,” the investigators noted.

Research also indicates that Black women are more likely to have lower levels of cortisol during the second trimester of pregnancy compared with women of other racial and ethnic groups. Cortisol is essential for fetal growth. Evidence links lower cortisol levels in later stages of pregnancy with decreased fetal growth in individuals who develop schizophrenia.

Black women have higher levels of certain stress biomarkers, including inflammatory C-reactive protein and adrenocorticotropic hormone, in mid- to late pregnancy, compared with White women of the same socioeconomic status.

Such findings “highlight a complex picture” involving maternal cortisol levels and other stress biomarkers, “potentially leading to poor birth outcomes and subsequent risk for psychotic disorders in adulthood,” the investigators noted.

The researchers call for the dismantling of structural racism and the social policies and norms it shapes. They also recommend changes in health care policy and in the approach to early intervention for psychosis among Black and other racially-minoritized groups.

“Altogether, the current evidence suggests the need to identify, address, and tackle the social determinants deeply ingrained in U.S. society, in tandem with empowering the most marginalized communities,” the researchers wrote.

“We recommend that the field of psychiatry devote considerably more effort to addressing structural racism and social determinants of psychosis in funding priorities, training, and intervention development,” they added.

Dr. Anglin suggests that mental health providers use what she called a “cultural formulation interview” that takes a person’s environmental and social context into consideration. Studies show that incorporating this into clinical practice helps reduce misdiagnosis of mental illness in Black populations, she said.
 

Call to action

Commenting on the findings in an interview, Ned H. Kalin, MD, editor of The American Journal of Psychiatry and professor and chair of the department of psychiatry, University of Wisconsin, Madison, said the study was well done and serves as a “call to action” to address the impact of structural racism on mental health issues and psychiatric diseases.

The article highlights the need for “collecting better data” on structural racism, said Dr. Kalin. “We know it’s a big issue, but we can’t even quantitate it, so we need some fundamental measures to use as a benchmark as we move forward, as we try to make change.”

He noted that racism “is so embedded in one’s experience and in our society that we sort of don’t even think about it as a trauma.”

In psychiatry, for example, trauma is often thought of as a loss or a traumatic event. “We don’t typically think of trauma as an experience that pervades one’s entire life,” but that needs to change, he said. “At the individual level and in the doctor’s office, being sensitive to and aware of these issues is absolutely critical.”

Dr. Anglin and Dr. Kalin have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

More than 11 million individuals in the United States identify as LGBTQ+, and data show that this population has a shorter life expectancy and increased rates of suicide, violence, and cardiovascular disease, according to Keshav Khanijow, MD, of Northwestern University, Chicago, and Nicole Rosendale, MD, of the University of California, San Francisco.

More than half of these individuals report experiencing discrimination, and one in three transgendered individuals have reported prejudice when visiting a doctor or health clinic, they said in a presentation at SHM Converge, the annual conference of the Society of Hospital Medicine.

“It is impossible to know how someone identifies by gender just by looking at them,” Dr. Rosendale emphasized.

However, attention to terminology, use of affirming language and documentation, and attention to clinical considerations can help LGBTQ+ patients feel comfortable in the health care setting.
 

Ask, don’t assume

Do ask patients how they identify themselves, Dr. Khanijow said. It is important to ask about sexual orientation as part of a social history. One big “Don’t” in terminology is to avoid the use of the term “homosexual,” he added. Although the description “homosexual” began as a scientific term, it has become associated with pathology, rather than identity, and is often used by hate groups. Also, do not assume sexual orientation based on a patient’s partner.

Always ask about sexual orientation before assuming it, and include that information in documentation. Dr. Khanijow used an example of a “one-liner” case of a 45-year-old male who self-identifies as “queer” and presents with a migraine. The most appropriate version would be “45yoM who identifies as queer with PMHx Migraines presents with Headache,” Dr. Khanijow said. However, as a clinician, consider why you are including sexual orientation in the one-liner. If there isn’t any real reason to include it (such as stress related to coming out, increased risk for other conditions) it may not be necessary in all visits.
 

Transgender considerations

Dr. Khanijow shared some specific considerations for the transgender/nonbinary population.

In terms of gender, “it is most respectful to identify the patient as they would like to be identified,” he said.

Ask how they identify their gender, including their preferred pronouns, and be sure to note this identification in their documents, he said. Be vigilant in addressing a transgender patient correctly. Mistakes happen, and when they do, correct yourself, apologize succinctly and move on.
 

Clinical challenges

Research on LGBTQ+ health is limited, and these individuals are often grouped into a single category despite diverse experiences, Dr. Rosendale said. Another limitation in LGBTQ+ research is that some studies assess based on identity (such as gay, lesbian, bisexual) while others assess behavior (studies of men who have sex with men).

Dr. Rosendale went on to highlight several important clinical concerns for the LGBTQ+ population. Compared with the general population, lesbian women are at higher risk for breast cancer, and gay men are at increased risk for prostate, colon, and testicular cancers. Potential heart disease risk factors of physical inactivity, obesity, and smoking are more prevalent among lesbian women, and tobacco and alcohol use are more prevalent among gay men, and men who have sex with men are at increased risk for STIs.

Clinicians also should be aware that “bisexual individuals face worse health outcomes than their lesbian, gay, and heterosexual counterparts,” Dr. Rosendale said.

LGBTQ+ patients often use hormone therapy, so clinicians should be aware of some potential adverse effects, Dr. Rosendale said. For example, trans women on gender-affirming estrogen therapy may have increased cardiovascular risks including incident MI, ischemic stroke, and cardiovascular mortality, compared with cisgender women.

In trans men, testosterone use has not been definitively linked to cardiovascular risk, although patients may show small changes in systolic blood pressure, lipid profiles, and blood glucose, Dr. Rosendale noted.
 

In-hospital issues

Inpatient and critical care of transgender and LGBTQ+ patients may have unique psychosocial considerations in hospital care, Dr. Rosendale said. To provide some guidance, a document on “Transgender-Affirming Hospital Policies” has been developed jointly by Lamda Legal, the Human Rights Campaign, the law firm of Hogan Lovells, and the New York City Bar.

Best practices noted in the document include rooming transgender individuals according to their identity, and recognizing that these patients may experience additional stress while an inpatient if personal clothing or other means of gender expression are replaced during the hospital stay, Dr. Rosendale noted.

Finally, clinicians seeing LGBTQ+ patients in an acute care setting should keep in mind that socioeconomic disparities may limit access to outpatient care, and that this population has higher rates of unemployment, exacerbated by the ongoing COVID-19 pandemic, Dr. Rosendale said. In addition, she advised clinicians to be aware that LGBTQ+ people may experience discrimination in rehabilitation centers, and their surrogate decision makers may be individuals other than family members.

Dr. Khanijow and Dr. Rosendale had no financial conflicts to disclose.

More than 11 million individuals in the United States identify as LGBTQ+, and data show that this population has a shorter life expectancy and increased rates of suicide, violence, and cardiovascular disease, according to Keshav Khanijow, MD, of Northwestern University, Chicago, and Nicole Rosendale, MD, of the University of California, San Francisco.

More than half of these individuals report experiencing discrimination, and one in three transgendered individuals have reported prejudice when visiting a doctor or health clinic, they said in a presentation at SHM Converge, the annual conference of the Society of Hospital Medicine.

“It is impossible to know how someone identifies by gender just by looking at them,” Dr. Rosendale emphasized.

However, attention to terminology, use of affirming language and documentation, and attention to clinical considerations can help LGBTQ+ patients feel comfortable in the health care setting.
 

Ask, don’t assume

Do ask patients how they identify themselves, Dr. Khanijow said. It is important to ask about sexual orientation as part of a social history. One big “Don’t” in terminology is to avoid the use of the term “homosexual,” he added. Although the description “homosexual” began as a scientific term, it has become associated with pathology, rather than identity, and is often used by hate groups. Also, do not assume sexual orientation based on a patient’s partner.

Always ask about sexual orientation before assuming it, and include that information in documentation. Dr. Khanijow used an example of a “one-liner” case of a 45-year-old male who self-identifies as “queer” and presents with a migraine. The most appropriate version would be “45yoM who identifies as queer with PMHx Migraines presents with Headache,” Dr. Khanijow said. However, as a clinician, consider why you are including sexual orientation in the one-liner. If there isn’t any real reason to include it (such as stress related to coming out, increased risk for other conditions) it may not be necessary in all visits.
 

Transgender considerations

Dr. Khanijow shared some specific considerations for the transgender/nonbinary population.

In terms of gender, “it is most respectful to identify the patient as they would like to be identified,” he said.

Ask how they identify their gender, including their preferred pronouns, and be sure to note this identification in their documents, he said. Be vigilant in addressing a transgender patient correctly. Mistakes happen, and when they do, correct yourself, apologize succinctly and move on.
 

Clinical challenges

Research on LGBTQ+ health is limited, and these individuals are often grouped into a single category despite diverse experiences, Dr. Rosendale said. Another limitation in LGBTQ+ research is that some studies assess based on identity (such as gay, lesbian, bisexual) while others assess behavior (studies of men who have sex with men).

Dr. Rosendale went on to highlight several important clinical concerns for the LGBTQ+ population. Compared with the general population, lesbian women are at higher risk for breast cancer, and gay men are at increased risk for prostate, colon, and testicular cancers. Potential heart disease risk factors of physical inactivity, obesity, and smoking are more prevalent among lesbian women, and tobacco and alcohol use are more prevalent among gay men, and men who have sex with men are at increased risk for STIs.

Clinicians also should be aware that “bisexual individuals face worse health outcomes than their lesbian, gay, and heterosexual counterparts,” Dr. Rosendale said.

LGBTQ+ patients often use hormone therapy, so clinicians should be aware of some potential adverse effects, Dr. Rosendale said. For example, trans women on gender-affirming estrogen therapy may have increased cardiovascular risks including incident MI, ischemic stroke, and cardiovascular mortality, compared with cisgender women.

In trans men, testosterone use has not been definitively linked to cardiovascular risk, although patients may show small changes in systolic blood pressure, lipid profiles, and blood glucose, Dr. Rosendale noted.
 

In-hospital issues

Inpatient and critical care of transgender and LGBTQ+ patients may have unique psychosocial considerations in hospital care, Dr. Rosendale said. To provide some guidance, a document on “Transgender-Affirming Hospital Policies” has been developed jointly by Lamda Legal, the Human Rights Campaign, the law firm of Hogan Lovells, and the New York City Bar.

Best practices noted in the document include rooming transgender individuals according to their identity, and recognizing that these patients may experience additional stress while an inpatient if personal clothing or other means of gender expression are replaced during the hospital stay, Dr. Rosendale noted.

Finally, clinicians seeing LGBTQ+ patients in an acute care setting should keep in mind that socioeconomic disparities may limit access to outpatient care, and that this population has higher rates of unemployment, exacerbated by the ongoing COVID-19 pandemic, Dr. Rosendale said. In addition, she advised clinicians to be aware that LGBTQ+ people may experience discrimination in rehabilitation centers, and their surrogate decision makers may be individuals other than family members.

Dr. Khanijow and Dr. Rosendale had no financial conflicts to disclose.

More than 11 million individuals in the United States identify as LGBTQ+, and data show that this population has a shorter life expectancy and increased rates of suicide, violence, and cardiovascular disease, according to Keshav Khanijow, MD, of Northwestern University, Chicago, and Nicole Rosendale, MD, of the University of California, San Francisco.

More than half of these individuals report experiencing discrimination, and one in three transgendered individuals have reported prejudice when visiting a doctor or health clinic, they said in a presentation at SHM Converge, the annual conference of the Society of Hospital Medicine.

“It is impossible to know how someone identifies by gender just by looking at them,” Dr. Rosendale emphasized.

However, attention to terminology, use of affirming language and documentation, and attention to clinical considerations can help LGBTQ+ patients feel comfortable in the health care setting.
 

Ask, don’t assume

Do ask patients how they identify themselves, Dr. Khanijow said. It is important to ask about sexual orientation as part of a social history. One big “Don’t” in terminology is to avoid the use of the term “homosexual,” he added. Although the description “homosexual” began as a scientific term, it has become associated with pathology, rather than identity, and is often used by hate groups. Also, do not assume sexual orientation based on a patient’s partner.

Always ask about sexual orientation before assuming it, and include that information in documentation. Dr. Khanijow used an example of a “one-liner” case of a 45-year-old male who self-identifies as “queer” and presents with a migraine. The most appropriate version would be “45yoM who identifies as queer with PMHx Migraines presents with Headache,” Dr. Khanijow said. However, as a clinician, consider why you are including sexual orientation in the one-liner. If there isn’t any real reason to include it (such as stress related to coming out, increased risk for other conditions) it may not be necessary in all visits.
 

Transgender considerations

Dr. Khanijow shared some specific considerations for the transgender/nonbinary population.

In terms of gender, “it is most respectful to identify the patient as they would like to be identified,” he said.

Ask how they identify their gender, including their preferred pronouns, and be sure to note this identification in their documents, he said. Be vigilant in addressing a transgender patient correctly. Mistakes happen, and when they do, correct yourself, apologize succinctly and move on.
 

Clinical challenges

Research on LGBTQ+ health is limited, and these individuals are often grouped into a single category despite diverse experiences, Dr. Rosendale said. Another limitation in LGBTQ+ research is that some studies assess based on identity (such as gay, lesbian, bisexual) while others assess behavior (studies of men who have sex with men).

Dr. Rosendale went on to highlight several important clinical concerns for the LGBTQ+ population. Compared with the general population, lesbian women are at higher risk for breast cancer, and gay men are at increased risk for prostate, colon, and testicular cancers. Potential heart disease risk factors of physical inactivity, obesity, and smoking are more prevalent among lesbian women, and tobacco and alcohol use are more prevalent among gay men, and men who have sex with men are at increased risk for STIs.

Clinicians also should be aware that “bisexual individuals face worse health outcomes than their lesbian, gay, and heterosexual counterparts,” Dr. Rosendale said.

LGBTQ+ patients often use hormone therapy, so clinicians should be aware of some potential adverse effects, Dr. Rosendale said. For example, trans women on gender-affirming estrogen therapy may have increased cardiovascular risks including incident MI, ischemic stroke, and cardiovascular mortality, compared with cisgender women.

In trans men, testosterone use has not been definitively linked to cardiovascular risk, although patients may show small changes in systolic blood pressure, lipid profiles, and blood glucose, Dr. Rosendale noted.
 

In-hospital issues

Inpatient and critical care of transgender and LGBTQ+ patients may have unique psychosocial considerations in hospital care, Dr. Rosendale said. To provide some guidance, a document on “Transgender-Affirming Hospital Policies” has been developed jointly by Lamda Legal, the Human Rights Campaign, the law firm of Hogan Lovells, and the New York City Bar.

Best practices noted in the document include rooming transgender individuals according to their identity, and recognizing that these patients may experience additional stress while an inpatient if personal clothing or other means of gender expression are replaced during the hospital stay, Dr. Rosendale noted.

Finally, clinicians seeing LGBTQ+ patients in an acute care setting should keep in mind that socioeconomic disparities may limit access to outpatient care, and that this population has higher rates of unemployment, exacerbated by the ongoing COVID-19 pandemic, Dr. Rosendale said. In addition, she advised clinicians to be aware that LGBTQ+ people may experience discrimination in rehabilitation centers, and their surrogate decision makers may be individuals other than family members.

Dr. Khanijow and Dr. Rosendale had no financial conflicts to disclose.

Working to mitigate racial and gender inequity in hospital medicine may seem like a daunting task, but every physician can play a role in turning the tide toward equity, according to Jorge Ganem, MD, FAAP.

“Talking about bias, racism, sexism, gender inequity, and health disparities is difficult,” Dr. Ganem, associate professor of pediatrics at the University of Texas at Austin and director of pediatric hospital medicine at Dell Children’s Medical Center in Austin, said May 5 at SHM Converge, the annual conference of the Society of Hospital Medicine. “There certainly comes a heavy weight and responsibility that we all feel. But I believe that we should approach gender inequities and racial disparities through a quality and patient safety lens, and looking through that lens.”

Dr. Ganem – along with Vanessa Durand, DO, FAAP, of St. Christopher’s Hospital for Children in Philadelphia, and Yemisi O. Jones, MD, FAAP, FHM, of Cincinnati Children’s Hospital – devised the concept of “functional allyship” as one way to improve representation in hospital medicine. The approach consists of three categories: listeners, amplifiers, and champions. Listeners are “those who take the time to listen and give space to the voices who are oppressed and disadvantaged,” Dr. Ganem said. “Action may not always be possible, but the space gives those who are marginalized validation to the feelings that the oppression produces.”

He described amplifiers as those who use their position of privilege to spread the message by educating their colleagues and other peers. “This includes elevating those from marginalized communities to speak on their own behalf and giving them the spotlight, given their expertise,” he said.

Champions are those who actively work to dismantle the oppression within systems. Dr. Ganem cited organizations such as ADVANCE PHM, FEMinEM and HeForShe as examples of national and global efforts, “but this also includes those working in committees that are addressing diversity and inclusion in their workplace and coming up with policies and procedures to increase equity,” he said.

Finding opportunities to practice mentorship and sponsorship are also important. “Positive mentorship relationships are key in avoiding burnout and decreasing attrition,” he said. “The development of successful mentorship programs are a must in order to retain women physicians and ‘underrepresented in medicine’ physicians in your organization.” He described a “sponsor” as someone who is in a position of influence and power who actively supports the career of a “protégé” whom they have identified as having high potential. “The sponsor may advance a protégé’s career by nominating them for leadership opportunities and introducing them into career networks,” he said.

Dr. Durand discussed additional ways to improve disparities of gender, race, and ethnicity. “It can all start with measuring the data,” said Dr. Durand, also an assistant professor of pediatrics at Drexel University, Philadelphia. “This means looking at gender and race and ethnicity data by unit or section at your institution, as well as leadership positions.” In 2017, authors led by Hilary Sanfey, MBBBCh, MHPE, FACS, published an article addressing strategies to identify and close the gender salary gap in surgery (J Am Coll Surg. 2017;225[2]:333-8). Their recommendations included changing policies, transparency, oversight of metrics, promoting women to senior leadership positions, and evaluating the organizational culture. “It goes back to culture, because it leads to accountability,” Dr. Durand said. “Behavior change comes with accountability.”

Part of holding people accountable within a culture change includes addressing microaggressions, or indirect expressions of prejudice. In 2016, authors led by Floyd Cheung, PhD., established a framework using the acronym A.C.T.I.O.N., which identifies a microaggression without being aggressive or evoking defensiveness towards the person communicating the microaggression. A.C.T.I.O.N. stands for Ask clarifying questions; Come from curiosity, not judgment; Tell what you observed in a factual manner; Impact exploration – discuss what the impact was; Own your own thoughts and feelings around the situation; and discuss Next steps.

“Granted, this might take a little time, but when we state microaggressions, most of us don’t realize that those statements could be hurtful or uncomfortable for the person receiving them,” Dr. Durand said.

Another strategy to address disparities involves partially blinding the interview process for trainees. “You can do this by not giving any ‘cognitive information’ to your interviewers – such as United States Medical Licensing Examination Step scores – that may anchor their position prior to the interview taking place,” she explained. “You can also standardize one or two questions that all interviewees have to answer, to have a more objective way to compare answers horizontally rather than vertically.”

This complements the notion of the Association of American Medical Colleges’ “holistic review,” a principle that it describes as allowing admissions committees “to consider the ‘whole’ applicant, rather than disproportionately focusing on any one factor.”

“The overall concept is to evaluate what are criteria of the position you are hiring for,” Dr. Durand said. “Different criteria will have different levels of importance. You would take into consideration the values of the group or the institution and make sure those criteria are most important for selection, at the forefront.”

Dr. Ganem and Dr. Durand reported having no financial disclosures.

Working to mitigate racial and gender inequity in hospital medicine may seem like a daunting task, but every physician can play a role in turning the tide toward equity, according to Jorge Ganem, MD, FAAP.

“Talking about bias, racism, sexism, gender inequity, and health disparities is difficult,” Dr. Ganem, associate professor of pediatrics at the University of Texas at Austin and director of pediatric hospital medicine at Dell Children’s Medical Center in Austin, said May 5 at SHM Converge, the annual conference of the Society of Hospital Medicine. “There certainly comes a heavy weight and responsibility that we all feel. But I believe that we should approach gender inequities and racial disparities through a quality and patient safety lens, and looking through that lens.”

Dr. Ganem – along with Vanessa Durand, DO, FAAP, of St. Christopher’s Hospital for Children in Philadelphia, and Yemisi O. Jones, MD, FAAP, FHM, of Cincinnati Children’s Hospital – devised the concept of “functional allyship” as one way to improve representation in hospital medicine. The approach consists of three categories: listeners, amplifiers, and champions. Listeners are “those who take the time to listen and give space to the voices who are oppressed and disadvantaged,” Dr. Ganem said. “Action may not always be possible, but the space gives those who are marginalized validation to the feelings that the oppression produces.”

He described amplifiers as those who use their position of privilege to spread the message by educating their colleagues and other peers. “This includes elevating those from marginalized communities to speak on their own behalf and giving them the spotlight, given their expertise,” he said.

Champions are those who actively work to dismantle the oppression within systems. Dr. Ganem cited organizations such as ADVANCE PHM, FEMinEM and HeForShe as examples of national and global efforts, “but this also includes those working in committees that are addressing diversity and inclusion in their workplace and coming up with policies and procedures to increase equity,” he said.

Finding opportunities to practice mentorship and sponsorship are also important. “Positive mentorship relationships are key in avoiding burnout and decreasing attrition,” he said. “The development of successful mentorship programs are a must in order to retain women physicians and ‘underrepresented in medicine’ physicians in your organization.” He described a “sponsor” as someone who is in a position of influence and power who actively supports the career of a “protégé” whom they have identified as having high potential. “The sponsor may advance a protégé’s career by nominating them for leadership opportunities and introducing them into career networks,” he said.

Dr. Durand discussed additional ways to improve disparities of gender, race, and ethnicity. “It can all start with measuring the data,” said Dr. Durand, also an assistant professor of pediatrics at Drexel University, Philadelphia. “This means looking at gender and race and ethnicity data by unit or section at your institution, as well as leadership positions.” In 2017, authors led by Hilary Sanfey, MBBBCh, MHPE, FACS, published an article addressing strategies to identify and close the gender salary gap in surgery (J Am Coll Surg. 2017;225[2]:333-8). Their recommendations included changing policies, transparency, oversight of metrics, promoting women to senior leadership positions, and evaluating the organizational culture. “It goes back to culture, because it leads to accountability,” Dr. Durand said. “Behavior change comes with accountability.”

Part of holding people accountable within a culture change includes addressing microaggressions, or indirect expressions of prejudice. In 2016, authors led by Floyd Cheung, PhD., established a framework using the acronym A.C.T.I.O.N., which identifies a microaggression without being aggressive or evoking defensiveness towards the person communicating the microaggression. A.C.T.I.O.N. stands for Ask clarifying questions; Come from curiosity, not judgment; Tell what you observed in a factual manner; Impact exploration – discuss what the impact was; Own your own thoughts and feelings around the situation; and discuss Next steps.

“Granted, this might take a little time, but when we state microaggressions, most of us don’t realize that those statements could be hurtful or uncomfortable for the person receiving them,” Dr. Durand said.

Another strategy to address disparities involves partially blinding the interview process for trainees. “You can do this by not giving any ‘cognitive information’ to your interviewers – such as United States Medical Licensing Examination Step scores – that may anchor their position prior to the interview taking place,” she explained. “You can also standardize one or two questions that all interviewees have to answer, to have a more objective way to compare answers horizontally rather than vertically.”

This complements the notion of the Association of American Medical Colleges’ “holistic review,” a principle that it describes as allowing admissions committees “to consider the ‘whole’ applicant, rather than disproportionately focusing on any one factor.”

“The overall concept is to evaluate what are criteria of the position you are hiring for,” Dr. Durand said. “Different criteria will have different levels of importance. You would take into consideration the values of the group or the institution and make sure those criteria are most important for selection, at the forefront.”

Dr. Ganem and Dr. Durand reported having no financial disclosures.

Working to mitigate racial and gender inequity in hospital medicine may seem like a daunting task, but every physician can play a role in turning the tide toward equity, according to Jorge Ganem, MD, FAAP.

“Talking about bias, racism, sexism, gender inequity, and health disparities is difficult,” Dr. Ganem, associate professor of pediatrics at the University of Texas at Austin and director of pediatric hospital medicine at Dell Children’s Medical Center in Austin, said May 5 at SHM Converge, the annual conference of the Society of Hospital Medicine. “There certainly comes a heavy weight and responsibility that we all feel. But I believe that we should approach gender inequities and racial disparities through a quality and patient safety lens, and looking through that lens.”

Dr. Ganem – along with Vanessa Durand, DO, FAAP, of St. Christopher’s Hospital for Children in Philadelphia, and Yemisi O. Jones, MD, FAAP, FHM, of Cincinnati Children’s Hospital – devised the concept of “functional allyship” as one way to improve representation in hospital medicine. The approach consists of three categories: listeners, amplifiers, and champions. Listeners are “those who take the time to listen and give space to the voices who are oppressed and disadvantaged,” Dr. Ganem said. “Action may not always be possible, but the space gives those who are marginalized validation to the feelings that the oppression produces.”

He described amplifiers as those who use their position of privilege to spread the message by educating their colleagues and other peers. “This includes elevating those from marginalized communities to speak on their own behalf and giving them the spotlight, given their expertise,” he said.

Champions are those who actively work to dismantle the oppression within systems. Dr. Ganem cited organizations such as ADVANCE PHM, FEMinEM and HeForShe as examples of national and global efforts, “but this also includes those working in committees that are addressing diversity and inclusion in their workplace and coming up with policies and procedures to increase equity,” he said.

Finding opportunities to practice mentorship and sponsorship are also important. “Positive mentorship relationships are key in avoiding burnout and decreasing attrition,” he said. “The development of successful mentorship programs are a must in order to retain women physicians and ‘underrepresented in medicine’ physicians in your organization.” He described a “sponsor” as someone who is in a position of influence and power who actively supports the career of a “protégé” whom they have identified as having high potential. “The sponsor may advance a protégé’s career by nominating them for leadership opportunities and introducing them into career networks,” he said.

Dr. Durand discussed additional ways to improve disparities of gender, race, and ethnicity. “It can all start with measuring the data,” said Dr. Durand, also an assistant professor of pediatrics at Drexel University, Philadelphia. “This means looking at gender and race and ethnicity data by unit or section at your institution, as well as leadership positions.” In 2017, authors led by Hilary Sanfey, MBBBCh, MHPE, FACS, published an article addressing strategies to identify and close the gender salary gap in surgery (J Am Coll Surg. 2017;225[2]:333-8). Their recommendations included changing policies, transparency, oversight of metrics, promoting women to senior leadership positions, and evaluating the organizational culture. “It goes back to culture, because it leads to accountability,” Dr. Durand said. “Behavior change comes with accountability.”

Part of holding people accountable within a culture change includes addressing microaggressions, or indirect expressions of prejudice. In 2016, authors led by Floyd Cheung, PhD., established a framework using the acronym A.C.T.I.O.N., which identifies a microaggression without being aggressive or evoking defensiveness towards the person communicating the microaggression. A.C.T.I.O.N. stands for Ask clarifying questions; Come from curiosity, not judgment; Tell what you observed in a factual manner; Impact exploration – discuss what the impact was; Own your own thoughts and feelings around the situation; and discuss Next steps.

“Granted, this might take a little time, but when we state microaggressions, most of us don’t realize that those statements could be hurtful or uncomfortable for the person receiving them,” Dr. Durand said.

Another strategy to address disparities involves partially blinding the interview process for trainees. “You can do this by not giving any ‘cognitive information’ to your interviewers – such as United States Medical Licensing Examination Step scores – that may anchor their position prior to the interview taking place,” she explained. “You can also standardize one or two questions that all interviewees have to answer, to have a more objective way to compare answers horizontally rather than vertically.”

This complements the notion of the Association of American Medical Colleges’ “holistic review,” a principle that it describes as allowing admissions committees “to consider the ‘whole’ applicant, rather than disproportionately focusing on any one factor.”

“The overall concept is to evaluate what are criteria of the position you are hiring for,” Dr. Durand said. “Different criteria will have different levels of importance. You would take into consideration the values of the group or the institution and make sure those criteria are most important for selection, at the forefront.”

Dr. Ganem and Dr. Durand reported having no financial disclosures.

Earlier this spring, Kimberly D. Manning, MD, FACP, FAAP, was caring for an elderly Black man with multiple comorbidities at Grady Memorial Hospital in Atlanta, assembling an order for medications and a discharge plan.

“It was very challenging,” Dr. Manning, professor of medicine and associate vice chair of diversity, equity, and inclusion at Emory University, Atlanta, recalled during a May 4 session at SHM Converge, the annual conference of the Society of Hospital Medicine.

At one point, the patient glanced at her, shrugged, and said: “You know, Doc, we get in where we fit in.”

“He was talking about the idea that people who come from historically disadvantaged backgrounds just have to try to figure it out, have to try to make a dollar out of 15 cents,” Dr. Manning said. “This, to me, really underscores what we mean when we say health disparities, this idea that there are people who are working hard and doing the best that they can but who still are forced to ‘get in where they fit in.’”

The Centers for Disease Control and Prevention defines health disparities as preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations. “When we think about health disparities we often think about many diagnoses,” Dr. Manning continued. “We think about HIV and the disparate care and outcomes we’ve seen in populations of individuals who come from minority backgrounds. We see disparities in obesity, cancer, cardiovascular disease, infant mortality and maternal death, hospital readmissions, and COVID-19. We know that people who do not have access to health care or to healthy neighborhoods and environments or who are economically disadvantaged have poorer outcomes. It plays out with all of these diagnoses.”

In her opinion, health disparities in hospital medicine fall into in one of three buckets: diagnosis and triage, hospital stay and treatment, and sticking the landing – “that is, after a patient leaves the hospital,” Dr. Manning explained. “The hospital stay is the turn on the balance beam. You can do everything perfectly, but then you must dismount. To score a ‘10’ you have to stick the landing. That means being able to get your medications, being able to get to and from clinic appointments, being able to understand the directions you’ve been given. All of these things are intertwined, the inpatient and outpatient care.”

The roots of health disparities in hospitalized patients stem from centuries ago, she said, when America’s health care system was built to benefit white male landowners and their families. Health care for Blacks, on the other hand, “was focused on function, almost like veterinary care, or experimentation,” Dr. Manning said. “After slavery ended, many historically Black institutions of higher learning opened, including medical schools. In 1909, there were seven historically Black medical schools. Acknowledging the history that preceded disparities is essential.”

In her view, the path to improving health care disparities starts with conceding that structural racism exists in the practice of medicine. “This means that health disparities are connected to systemic and individual issues, including our biases,” Dr. Manning said. “Our system was built on this idea that there is greater value of one group of people above others. Access to care, physician workforce, and biases are impacted by system design. Health equity and health equality are not the same.”

She also underscored the importance of the social determinants of health, or “those things we need to be healthy,” including economic stability, neighborhood and physical environment, educational opportunities, access to good food, community and social context, and the idea of health care as a human right and understanding our health care system. “This is what is necessary,” she declared. “Without all of these together, we can’t have the health outcomes that we desire.”

As hospital leaders work to build a more diverse physician workforce, Dr. Manning emphasized the importance of forming antiracism policies by addressing questions such as what will we not stand for? How will we protect and create psychologically safe environments? What is our commitment to diversity in leadership and in trainees? What is our commitment to implicit bias training and bystander training?

“We have to get uncomfortable enough to advocate with urgency because all of these are necessary factors to mitigate health disparities,” she said. “Though the systemic issues are the most urgent, on an individual level, we must continue to disrupt the negative ideology and stereotypes that threaten our environment every day. When we see those negative things, we have to call them out. We need to continue to listen, to humanize those things that are happening around us, and to understand historical context.”

Dr. Manning reported having no financial disclosures.

Earlier this spring, Kimberly D. Manning, MD, FACP, FAAP, was caring for an elderly Black man with multiple comorbidities at Grady Memorial Hospital in Atlanta, assembling an order for medications and a discharge plan.

“It was very challenging,” Dr. Manning, professor of medicine and associate vice chair of diversity, equity, and inclusion at Emory University, Atlanta, recalled during a May 4 session at SHM Converge, the annual conference of the Society of Hospital Medicine.

At one point, the patient glanced at her, shrugged, and said: “You know, Doc, we get in where we fit in.”

“He was talking about the idea that people who come from historically disadvantaged backgrounds just have to try to figure it out, have to try to make a dollar out of 15 cents,” Dr. Manning said. “This, to me, really underscores what we mean when we say health disparities, this idea that there are people who are working hard and doing the best that they can but who still are forced to ‘get in where they fit in.’”

The Centers for Disease Control and Prevention defines health disparities as preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations. “When we think about health disparities we often think about many diagnoses,” Dr. Manning continued. “We think about HIV and the disparate care and outcomes we’ve seen in populations of individuals who come from minority backgrounds. We see disparities in obesity, cancer, cardiovascular disease, infant mortality and maternal death, hospital readmissions, and COVID-19. We know that people who do not have access to health care or to healthy neighborhoods and environments or who are economically disadvantaged have poorer outcomes. It plays out with all of these diagnoses.”

In her opinion, health disparities in hospital medicine fall into in one of three buckets: diagnosis and triage, hospital stay and treatment, and sticking the landing – “that is, after a patient leaves the hospital,” Dr. Manning explained. “The hospital stay is the turn on the balance beam. You can do everything perfectly, but then you must dismount. To score a ‘10’ you have to stick the landing. That means being able to get your medications, being able to get to and from clinic appointments, being able to understand the directions you’ve been given. All of these things are intertwined, the inpatient and outpatient care.”

The roots of health disparities in hospitalized patients stem from centuries ago, she said, when America’s health care system was built to benefit white male landowners and their families. Health care for Blacks, on the other hand, “was focused on function, almost like veterinary care, or experimentation,” Dr. Manning said. “After slavery ended, many historically Black institutions of higher learning opened, including medical schools. In 1909, there were seven historically Black medical schools. Acknowledging the history that preceded disparities is essential.”

In her view, the path to improving health care disparities starts with conceding that structural racism exists in the practice of medicine. “This means that health disparities are connected to systemic and individual issues, including our biases,” Dr. Manning said. “Our system was built on this idea that there is greater value of one group of people above others. Access to care, physician workforce, and biases are impacted by system design. Health equity and health equality are not the same.”

She also underscored the importance of the social determinants of health, or “those things we need to be healthy,” including economic stability, neighborhood and physical environment, educational opportunities, access to good food, community and social context, and the idea of health care as a human right and understanding our health care system. “This is what is necessary,” she declared. “Without all of these together, we can’t have the health outcomes that we desire.”

As hospital leaders work to build a more diverse physician workforce, Dr. Manning emphasized the importance of forming antiracism policies by addressing questions such as what will we not stand for? How will we protect and create psychologically safe environments? What is our commitment to diversity in leadership and in trainees? What is our commitment to implicit bias training and bystander training?

“We have to get uncomfortable enough to advocate with urgency because all of these are necessary factors to mitigate health disparities,” she said. “Though the systemic issues are the most urgent, on an individual level, we must continue to disrupt the negative ideology and stereotypes that threaten our environment every day. When we see those negative things, we have to call them out. We need to continue to listen, to humanize those things that are happening around us, and to understand historical context.”

Dr. Manning reported having no financial disclosures.

Earlier this spring, Kimberly D. Manning, MD, FACP, FAAP, was caring for an elderly Black man with multiple comorbidities at Grady Memorial Hospital in Atlanta, assembling an order for medications and a discharge plan.

“It was very challenging,” Dr. Manning, professor of medicine and associate vice chair of diversity, equity, and inclusion at Emory University, Atlanta, recalled during a May 4 session at SHM Converge, the annual conference of the Society of Hospital Medicine.

At one point, the patient glanced at her, shrugged, and said: “You know, Doc, we get in where we fit in.”

“He was talking about the idea that people who come from historically disadvantaged backgrounds just have to try to figure it out, have to try to make a dollar out of 15 cents,” Dr. Manning said. “This, to me, really underscores what we mean when we say health disparities, this idea that there are people who are working hard and doing the best that they can but who still are forced to ‘get in where they fit in.’”

The Centers for Disease Control and Prevention defines health disparities as preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations. “When we think about health disparities we often think about many diagnoses,” Dr. Manning continued. “We think about HIV and the disparate care and outcomes we’ve seen in populations of individuals who come from minority backgrounds. We see disparities in obesity, cancer, cardiovascular disease, infant mortality and maternal death, hospital readmissions, and COVID-19. We know that people who do not have access to health care or to healthy neighborhoods and environments or who are economically disadvantaged have poorer outcomes. It plays out with all of these diagnoses.”

In her opinion, health disparities in hospital medicine fall into in one of three buckets: diagnosis and triage, hospital stay and treatment, and sticking the landing – “that is, after a patient leaves the hospital,” Dr. Manning explained. “The hospital stay is the turn on the balance beam. You can do everything perfectly, but then you must dismount. To score a ‘10’ you have to stick the landing. That means being able to get your medications, being able to get to and from clinic appointments, being able to understand the directions you’ve been given. All of these things are intertwined, the inpatient and outpatient care.”

The roots of health disparities in hospitalized patients stem from centuries ago, she said, when America’s health care system was built to benefit white male landowners and their families. Health care for Blacks, on the other hand, “was focused on function, almost like veterinary care, or experimentation,” Dr. Manning said. “After slavery ended, many historically Black institutions of higher learning opened, including medical schools. In 1909, there were seven historically Black medical schools. Acknowledging the history that preceded disparities is essential.”

In her view, the path to improving health care disparities starts with conceding that structural racism exists in the practice of medicine. “This means that health disparities are connected to systemic and individual issues, including our biases,” Dr. Manning said. “Our system was built on this idea that there is greater value of one group of people above others. Access to care, physician workforce, and biases are impacted by system design. Health equity and health equality are not the same.”

She also underscored the importance of the social determinants of health, or “those things we need to be healthy,” including economic stability, neighborhood and physical environment, educational opportunities, access to good food, community and social context, and the idea of health care as a human right and understanding our health care system. “This is what is necessary,” she declared. “Without all of these together, we can’t have the health outcomes that we desire.”

As hospital leaders work to build a more diverse physician workforce, Dr. Manning emphasized the importance of forming antiracism policies by addressing questions such as what will we not stand for? How will we protect and create psychologically safe environments? What is our commitment to diversity in leadership and in trainees? What is our commitment to implicit bias training and bystander training?

“We have to get uncomfortable enough to advocate with urgency because all of these are necessary factors to mitigate health disparities,” she said. “Though the systemic issues are the most urgent, on an individual level, we must continue to disrupt the negative ideology and stereotypes that threaten our environment every day. When we see those negative things, we have to call them out. We need to continue to listen, to humanize those things that are happening around us, and to understand historical context.”

Dr. Manning reported having no financial disclosures.

In the analysis of images for detecting potential pathology, artificial intelligence (AI) is showing enormous promise across multiple fields of medicine. But the technology in dermatology is bound to fail in skin of color if training does not specifically address these skin types, according to Adewole S. Adamson, MD, who outlined this issue at the American Academy of Dermatology Virtual Meeting Experience.

“Machine learning algorithms are only as good as the inputs through which they learn. Without representation from individuals with skin of color, we are at risk of creating a new source of racial disparity in patient care,” Dr. Adamson, assistant professor in the division of dermatology, department of internal medicine, University of Texas at Austin, said at the meeting.

Diagnostic algorithms using AI are typically based on deep learning, a subset of machine learning that depends on artificial neural networks. In the case of image processing, neural networks can “learn” to recognize objects, faces, or, in the realm of health care, disease, from exposure to multiple images.

There are many other variables that affect the accuracy of deep learning for diagnostic algorithms, including the depth of the layering through which the process distills multiple inputs of information, but the number of inputs is critical. In the case of skin lesions, machines cannot learn to recognize features of different skin types without exposure.

“There are studies demonstrating that dermatologists can be outperformed for detection of skin cancers by AI, so this is going to be an increasingly powerful tool,” Dr. Adamson said. The problem is that “there has been very little representation in darker skin types” in the algorithms developed so far.

The risk is that AI will exacerbate an existing problem. Skin cancer in darker skin is less common but already underdiagnosed, independent of AI. Per 100,000 males in the United States, the rate of melanoma is about 30-fold greater in White men than in Black men (33.0 vs. 1.0). Among females, the racial difference is smaller but still enormous (20.2 vs. 1.2 per 100,000 females), according to U.S. data.

For the low representation of darker skin in studies so far with AI, “one of the arguments is that skin cancer is not a big deal in darker skin types,” Dr. Adamson said.

It might be the other way around. The relative infrequency with which skin cancer occurs in the Black population in the United States might explain a low level of suspicion and ultimately delays in diagnosis, which, in turn, leads to worse outcomes. According to one analysis drawn from the Surveillance, Epidemiology and End-Result (SEER) database (1998-2011), the proportion of patients with regionally advanced or distant disease was nearly twice as great (11.6% vs. 6.0%; P < .05) in Black patients, relative to White patients.

Not surprisingly, given the importance of early diagnosis of cancers overall and skin cancer specifically, the mean survival for malignant melanoma in Black patients was almost 4 years lower than in White patients (10.8 vs. 14.6 years; P < .001) for nodular melanoma, the same study found.

In humans, bias is reasonably attributed in many cases to judgments made on a small sample size. The problem in AI is analogous. Dr. Adamson, who has published research on the potential for machine learning to contribute to health care disparities in dermatology, cited work done by Joy Buolamwini, a graduate researcher in the media lab at the Massachusetts Institute of Technology. In one study she conducted, the rate of AI facial recognition failure was 1% in White males, 7% in White females, 12% in skin-of-color males, and 35% in skin-of-color females. Fewer inputs of skin of color is the likely explanation, Dr. Adamson said.

The potential for racial bias from AI in the diagnosis of disease increases and becomes more complex when inputs beyond imaging, such as past medical history, are included. Dr. Adamson warned of the potential for “bias to creep in” when there is failure to account for societal, cultural, or other differences that distinguish one patient group from another. However, for skin cancer or other diseases based on images alone, he said there are solutions.

“We are in the early days, and there is time to change this,” Dr. Adamson said, referring to the low representation of skin of color in AI training sets. In addition to including more skin types to train recognition, creating AI algorithms specifically for dark skin is another potential approach.

However, his key point was the importance of recognizing the need for solutions.

“AI is the future, but we must apply the same rigor to AI as to other medical interventions to ensure that the technology is not applied in a biased fashion,” he said.

Susan M. Swetter, MD, professor of dermatology and director of the pigmented lesion and melanoma program at Stanford (Calif.) University Medical Center and Cancer Institute, agreed. As someone who has been following the progress of AI in the diagnosis of skin cancer, Dr. Swetter recognizes the potential for this technology to increase diagnostic efficiency and accuracy, but she also called for studies specific to skin of color.

In the analysis of images for detecting potential pathology, artificial intelligence (AI) is showing enormous promise across multiple fields of medicine. But the technology in dermatology is bound to fail in skin of color if training does not specifically address these skin types, according to Adewole S. Adamson, MD, who outlined this issue at the American Academy of Dermatology Virtual Meeting Experience.

“Machine learning algorithms are only as good as the inputs through which they learn. Without representation from individuals with skin of color, we are at risk of creating a new source of racial disparity in patient care,” Dr. Adamson, assistant professor in the division of dermatology, department of internal medicine, University of Texas at Austin, said at the meeting.

Diagnostic algorithms using AI are typically based on deep learning, a subset of machine learning that depends on artificial neural networks. In the case of image processing, neural networks can “learn” to recognize objects, faces, or, in the realm of health care, disease, from exposure to multiple images.

There are many other variables that affect the accuracy of deep learning for diagnostic algorithms, including the depth of the layering through which the process distills multiple inputs of information, but the number of inputs is critical. In the case of skin lesions, machines cannot learn to recognize features of different skin types without exposure.

“There are studies demonstrating that dermatologists can be outperformed for detection of skin cancers by AI, so this is going to be an increasingly powerful tool,” Dr. Adamson said. The problem is that “there has been very little representation in darker skin types” in the algorithms developed so far.

The risk is that AI will exacerbate an existing problem. Skin cancer in darker skin is less common but already underdiagnosed, independent of AI. Per 100,000 males in the United States, the rate of melanoma is about 30-fold greater in White men than in Black men (33.0 vs. 1.0). Among females, the racial difference is smaller but still enormous (20.2 vs. 1.2 per 100,000 females), according to U.S. data.

For the low representation of darker skin in studies so far with AI, “one of the arguments is that skin cancer is not a big deal in darker skin types,” Dr. Adamson said.

It might be the other way around. The relative infrequency with which skin cancer occurs in the Black population in the United States might explain a low level of suspicion and ultimately delays in diagnosis, which, in turn, leads to worse outcomes. According to one analysis drawn from the Surveillance, Epidemiology and End-Result (SEER) database (1998-2011), the proportion of patients with regionally advanced or distant disease was nearly twice as great (11.6% vs. 6.0%; P < .05) in Black patients, relative to White patients.

Not surprisingly, given the importance of early diagnosis of cancers overall and skin cancer specifically, the mean survival for malignant melanoma in Black patients was almost 4 years lower than in White patients (10.8 vs. 14.6 years; P < .001) for nodular melanoma, the same study found.

In humans, bias is reasonably attributed in many cases to judgments made on a small sample size. The problem in AI is analogous. Dr. Adamson, who has published research on the potential for machine learning to contribute to health care disparities in dermatology, cited work done by Joy Buolamwini, a graduate researcher in the media lab at the Massachusetts Institute of Technology. In one study she conducted, the rate of AI facial recognition failure was 1% in White males, 7% in White females, 12% in skin-of-color males, and 35% in skin-of-color females. Fewer inputs of skin of color is the likely explanation, Dr. Adamson said.

The potential for racial bias from AI in the diagnosis of disease increases and becomes more complex when inputs beyond imaging, such as past medical history, are included. Dr. Adamson warned of the potential for “bias to creep in” when there is failure to account for societal, cultural, or other differences that distinguish one patient group from another. However, for skin cancer or other diseases based on images alone, he said there are solutions.

“We are in the early days, and there is time to change this,” Dr. Adamson said, referring to the low representation of skin of color in AI training sets. In addition to including more skin types to train recognition, creating AI algorithms specifically for dark skin is another potential approach.

However, his key point was the importance of recognizing the need for solutions.

“AI is the future, but we must apply the same rigor to AI as to other medical interventions to ensure that the technology is not applied in a biased fashion,” he said.

Susan M. Swetter, MD, professor of dermatology and director of the pigmented lesion and melanoma program at Stanford (Calif.) University Medical Center and Cancer Institute, agreed. As someone who has been following the progress of AI in the diagnosis of skin cancer, Dr. Swetter recognizes the potential for this technology to increase diagnostic efficiency and accuracy, but she also called for studies specific to skin of color.

In the analysis of images for detecting potential pathology, artificial intelligence (AI) is showing enormous promise across multiple fields of medicine. But the technology in dermatology is bound to fail in skin of color if training does not specifically address these skin types, according to Adewole S. Adamson, MD, who outlined this issue at the American Academy of Dermatology Virtual Meeting Experience.

“Machine learning algorithms are only as good as the inputs through which they learn. Without representation from individuals with skin of color, we are at risk of creating a new source of racial disparity in patient care,” Dr. Adamson, assistant professor in the division of dermatology, department of internal medicine, University of Texas at Austin, said at the meeting.

Diagnostic algorithms using AI are typically based on deep learning, a subset of machine learning that depends on artificial neural networks. In the case of image processing, neural networks can “learn” to recognize objects, faces, or, in the realm of health care, disease, from exposure to multiple images.

There are many other variables that affect the accuracy of deep learning for diagnostic algorithms, including the depth of the layering through which the process distills multiple inputs of information, but the number of inputs is critical. In the case of skin lesions, machines cannot learn to recognize features of different skin types without exposure.

“There are studies demonstrating that dermatologists can be outperformed for detection of skin cancers by AI, so this is going to be an increasingly powerful tool,” Dr. Adamson said. The problem is that “there has been very little representation in darker skin types” in the algorithms developed so far.

The risk is that AI will exacerbate an existing problem. Skin cancer in darker skin is less common but already underdiagnosed, independent of AI. Per 100,000 males in the United States, the rate of melanoma is about 30-fold greater in White men than in Black men (33.0 vs. 1.0). Among females, the racial difference is smaller but still enormous (20.2 vs. 1.2 per 100,000 females), according to U.S. data.

For the low representation of darker skin in studies so far with AI, “one of the arguments is that skin cancer is not a big deal in darker skin types,” Dr. Adamson said.

It might be the other way around. The relative infrequency with which skin cancer occurs in the Black population in the United States might explain a low level of suspicion and ultimately delays in diagnosis, which, in turn, leads to worse outcomes. According to one analysis drawn from the Surveillance, Epidemiology and End-Result (SEER) database (1998-2011), the proportion of patients with regionally advanced or distant disease was nearly twice as great (11.6% vs. 6.0%; P < .05) in Black patients, relative to White patients.

Not surprisingly, given the importance of early diagnosis of cancers overall and skin cancer specifically, the mean survival for malignant melanoma in Black patients was almost 4 years lower than in White patients (10.8 vs. 14.6 years; P < .001) for nodular melanoma, the same study found.

In humans, bias is reasonably attributed in many cases to judgments made on a small sample size. The problem in AI is analogous. Dr. Adamson, who has published research on the potential for machine learning to contribute to health care disparities in dermatology, cited work done by Joy Buolamwini, a graduate researcher in the media lab at the Massachusetts Institute of Technology. In one study she conducted, the rate of AI facial recognition failure was 1% in White males, 7% in White females, 12% in skin-of-color males, and 35% in skin-of-color females. Fewer inputs of skin of color is the likely explanation, Dr. Adamson said.

The potential for racial bias from AI in the diagnosis of disease increases and becomes more complex when inputs beyond imaging, such as past medical history, are included. Dr. Adamson warned of the potential for “bias to creep in” when there is failure to account for societal, cultural, or other differences that distinguish one patient group from another. However, for skin cancer or other diseases based on images alone, he said there are solutions.

“We are in the early days, and there is time to change this,” Dr. Adamson said, referring to the low representation of skin of color in AI training sets. In addition to including more skin types to train recognition, creating AI algorithms specifically for dark skin is another potential approach.

However, his key point was the importance of recognizing the need for solutions.

“AI is the future, but we must apply the same rigor to AI as to other medical interventions to ensure that the technology is not applied in a biased fashion,” he said.

Susan M. Swetter, MD, professor of dermatology and director of the pigmented lesion and melanoma program at Stanford (Calif.) University Medical Center and Cancer Institute, agreed. As someone who has been following the progress of AI in the diagnosis of skin cancer, Dr. Swetter recognizes the potential for this technology to increase diagnostic efficiency and accuracy, but she also called for studies specific to skin of color.

Inequities in the initial growth of transcatheter aortic valve replacement (TAVR) programs in American hospitals has led to less use of the transformative procedure in poorer communities, a new cross-sectional study suggests.

Using Medicare claims data, investigators identified 554 new TAVR programs created between January 2012 and December 2018.

Of these, 98% were established in metropolitan areas (>50,000 residents) and 53% were started in areas with preexisting TAVR programs, “thereby increasing the number of programs but not necessarily increasing the geographic availability of the procedure,” said study author Ashwin Nathan, MD, Hospital of the University of Pennsylvania, Philadelphia.

Only 11 programs were started in nonmetropolitan areas over the study period, he noted during the featured clinical research presentation at the Society for Cardiovascular Angiography and Interventions (SCAI) 2021 annual scientific sessions, held virtually this year.

Hospitals that established TAVR programs, compared with those that did not, cared for patients with higher median household incomes (difference, $1,305; P = .03) and from areas with better economic well-being based on the Distressed Communities Index (difference, –3.15 units; P < .01), and cared for fewer patients with dual eligibility for Medicaid (difference, –3.15%; P < .01).

When the investigators looked at rates of TAVR between the core-based statistical areas, there were fewer TAVR procedures per 100,000 Medicare beneficiaries in areas with more Medicaid dual-eligible patients (difference, –1.19% per 1% increase), lower average median household incomes (difference, –0.62% per $1,000 decrease), and more average community distress (difference, –0.35% per 1 unit increase; P < .01 for all).

“What we can conclude is that the increased number of TAVR programs that we found during the study period did not necessarily translate to increased access to TAVR ... Wealthy, more privileged patients had more access to TAVR by virtue of the hospitals that serve them,” Dr. Nathan said.

Future steps, he said, are to identify the role of race and ethnicity in inequitable access to TAVR, identify system- and patient-level barriers to access, and to develop and test solutions to address inequitable care.

Elaborating on the latter point during a discussion of the results, study coauthor Jay S. Giri, MD, MPH, also from the Hospital of the University of Pennsylvania, observed that although the data showed rural areas are left behind, not every part of an urban area acts like the area more generally.

As a result, they’re delving into the 25 largest urban areas and trying to disaggregate, based on both socioeconomic status and race within the area, whether inequities exist, he said. “Believe it or not, in some urban areas where there clearly is access – there might even be a dozen TAVR programs within a 25 mile radius – do some of those areas still act like rural areas that don’t have access? So more to come on that.”

Session comoderator Steven Yakubov, MD, MidWest Cardiology Research Foundation in Columbus, Ohio, said the results show TAVR programs tend to be developed in well-served areas but asked whether some of the responsibility falls on patients to seek medical attention. “Do we just not give enough education to patients on how to access care?”

Dr. Giri responded by highlighting the complexity of navigating from even being diagnosed with aortic stenosis to making it through a multidisciplinary TAVR evaluation.

“Individuals with increased health literacy and more means are more likely to make it through that gauntlet. But from a public health perspective, obviously, I’d argue that the onus is probably more on the medical community at large to figure out how to roll these programs out more widespread,” he said.

“It looked to us like market forces overwhelmingly seemed to drive the development of new TAVR programs over access to care considerations,” Dr. Giri added. “And just to point out, those market forces aren’t at the level of the device manufacturers, who are often maligned for cost. This is really about the market forces at the level of hospitals and health systems.”

Session comoderator Megan Coylewright, MD, MPH, Erlanger Heart and Lung Institute, Chattanooga, Tenn., said, “I think that’s really well stated,” and noted that physicians may bear some responsibility as well.

“From a physician responsibility, especially for structural heart, we tended to all aggregate together, all of us that have structural heart training or that have trained in certain institutions,” she said. “It’s certainly on us to continue to spread out and go to the communities in need to ensure access. I think, as Dr. Giri said, there are a lot of solutions and that needs to be the focus for the next couple of years.”

Dr. Nathan reported having no relevant disclosures. Dr. Giri reported serving as a principal investigator for a research study for Boston Scientific, Inari Medical, Abbott, and Recor Medical; consulting for Boston Scientific; and serving on an advisory board for Inari Medical.

A version of this article first appeared on Medscape.com.

Inequities in the initial growth of transcatheter aortic valve replacement (TAVR) programs in American hospitals has led to less use of the transformative procedure in poorer communities, a new cross-sectional study suggests.

Using Medicare claims data, investigators identified 554 new TAVR programs created between January 2012 and December 2018.

Of these, 98% were established in metropolitan areas (>50,000 residents) and 53% were started in areas with preexisting TAVR programs, “thereby increasing the number of programs but not necessarily increasing the geographic availability of the procedure,” said study author Ashwin Nathan, MD, Hospital of the University of Pennsylvania, Philadelphia.

Only 11 programs were started in nonmetropolitan areas over the study period, he noted during the featured clinical research presentation at the Society for Cardiovascular Angiography and Interventions (SCAI) 2021 annual scientific sessions, held virtually this year.

Hospitals that established TAVR programs, compared with those that did not, cared for patients with higher median household incomes (difference, $1,305; P = .03) and from areas with better economic well-being based on the Distressed Communities Index (difference, –3.15 units; P < .01), and cared for fewer patients with dual eligibility for Medicaid (difference, –3.15%; P < .01).

When the investigators looked at rates of TAVR between the core-based statistical areas, there were fewer TAVR procedures per 100,000 Medicare beneficiaries in areas with more Medicaid dual-eligible patients (difference, –1.19% per 1% increase), lower average median household incomes (difference, –0.62% per $1,000 decrease), and more average community distress (difference, –0.35% per 1 unit increase; P < .01 for all).

“What we can conclude is that the increased number of TAVR programs that we found during the study period did not necessarily translate to increased access to TAVR ... Wealthy, more privileged patients had more access to TAVR by virtue of the hospitals that serve them,” Dr. Nathan said.

Future steps, he said, are to identify the role of race and ethnicity in inequitable access to TAVR, identify system- and patient-level barriers to access, and to develop and test solutions to address inequitable care.

Elaborating on the latter point during a discussion of the results, study coauthor Jay S. Giri, MD, MPH, also from the Hospital of the University of Pennsylvania, observed that although the data showed rural areas are left behind, not every part of an urban area acts like the area more generally.

As a result, they’re delving into the 25 largest urban areas and trying to disaggregate, based on both socioeconomic status and race within the area, whether inequities exist, he said. “Believe it or not, in some urban areas where there clearly is access – there might even be a dozen TAVR programs within a 25 mile radius – do some of those areas still act like rural areas that don’t have access? So more to come on that.”

Session comoderator Steven Yakubov, MD, MidWest Cardiology Research Foundation in Columbus, Ohio, said the results show TAVR programs tend to be developed in well-served areas but asked whether some of the responsibility falls on patients to seek medical attention. “Do we just not give enough education to patients on how to access care?”

Dr. Giri responded by highlighting the complexity of navigating from even being diagnosed with aortic stenosis to making it through a multidisciplinary TAVR evaluation.

“Individuals with increased health literacy and more means are more likely to make it through that gauntlet. But from a public health perspective, obviously, I’d argue that the onus is probably more on the medical community at large to figure out how to roll these programs out more widespread,” he said.

“It looked to us like market forces overwhelmingly seemed to drive the development of new TAVR programs over access to care considerations,” Dr. Giri added. “And just to point out, those market forces aren’t at the level of the device manufacturers, who are often maligned for cost. This is really about the market forces at the level of hospitals and health systems.”

Session comoderator Megan Coylewright, MD, MPH, Erlanger Heart and Lung Institute, Chattanooga, Tenn., said, “I think that’s really well stated,” and noted that physicians may bear some responsibility as well.

“From a physician responsibility, especially for structural heart, we tended to all aggregate together, all of us that have structural heart training or that have trained in certain institutions,” she said. “It’s certainly on us to continue to spread out and go to the communities in need to ensure access. I think, as Dr. Giri said, there are a lot of solutions and that needs to be the focus for the next couple of years.”

Dr. Nathan reported having no relevant disclosures. Dr. Giri reported serving as a principal investigator for a research study for Boston Scientific, Inari Medical, Abbott, and Recor Medical; consulting for Boston Scientific; and serving on an advisory board for Inari Medical.

A version of this article first appeared on Medscape.com.

Inequities in the initial growth of transcatheter aortic valve replacement (TAVR) programs in American hospitals has led to less use of the transformative procedure in poorer communities, a new cross-sectional study suggests.

Using Medicare claims data, investigators identified 554 new TAVR programs created between January 2012 and December 2018.

Of these, 98% were established in metropolitan areas (>50,000 residents) and 53% were started in areas with preexisting TAVR programs, “thereby increasing the number of programs but not necessarily increasing the geographic availability of the procedure,” said study author Ashwin Nathan, MD, Hospital of the University of Pennsylvania, Philadelphia.

Only 11 programs were started in nonmetropolitan areas over the study period, he noted during the featured clinical research presentation at the Society for Cardiovascular Angiography and Interventions (SCAI) 2021 annual scientific sessions, held virtually this year.

Hospitals that established TAVR programs, compared with those that did not, cared for patients with higher median household incomes (difference, $1,305; P = .03) and from areas with better economic well-being based on the Distressed Communities Index (difference, –3.15 units; P < .01), and cared for fewer patients with dual eligibility for Medicaid (difference, –3.15%; P < .01).

When the investigators looked at rates of TAVR between the core-based statistical areas, there were fewer TAVR procedures per 100,000 Medicare beneficiaries in areas with more Medicaid dual-eligible patients (difference, –1.19% per 1% increase), lower average median household incomes (difference, –0.62% per $1,000 decrease), and more average community distress (difference, –0.35% per 1 unit increase; P < .01 for all).

“What we can conclude is that the increased number of TAVR programs that we found during the study period did not necessarily translate to increased access to TAVR ... Wealthy, more privileged patients had more access to TAVR by virtue of the hospitals that serve them,” Dr. Nathan said.

Future steps, he said, are to identify the role of race and ethnicity in inequitable access to TAVR, identify system- and patient-level barriers to access, and to develop and test solutions to address inequitable care.

Elaborating on the latter point during a discussion of the results, study coauthor Jay S. Giri, MD, MPH, also from the Hospital of the University of Pennsylvania, observed that although the data showed rural areas are left behind, not every part of an urban area acts like the area more generally.

As a result, they’re delving into the 25 largest urban areas and trying to disaggregate, based on both socioeconomic status and race within the area, whether inequities exist, he said. “Believe it or not, in some urban areas where there clearly is access – there might even be a dozen TAVR programs within a 25 mile radius – do some of those areas still act like rural areas that don’t have access? So more to come on that.”

Session comoderator Steven Yakubov, MD, MidWest Cardiology Research Foundation in Columbus, Ohio, said the results show TAVR programs tend to be developed in well-served areas but asked whether some of the responsibility falls on patients to seek medical attention. “Do we just not give enough education to patients on how to access care?”

Dr. Giri responded by highlighting the complexity of navigating from even being diagnosed with aortic stenosis to making it through a multidisciplinary TAVR evaluation.

“Individuals with increased health literacy and more means are more likely to make it through that gauntlet. But from a public health perspective, obviously, I’d argue that the onus is probably more on the medical community at large to figure out how to roll these programs out more widespread,” he said.

“It looked to us like market forces overwhelmingly seemed to drive the development of new TAVR programs over access to care considerations,” Dr. Giri added. “And just to point out, those market forces aren’t at the level of the device manufacturers, who are often maligned for cost. This is really about the market forces at the level of hospitals and health systems.”

Session comoderator Megan Coylewright, MD, MPH, Erlanger Heart and Lung Institute, Chattanooga, Tenn., said, “I think that’s really well stated,” and noted that physicians may bear some responsibility as well.

“From a physician responsibility, especially for structural heart, we tended to all aggregate together, all of us that have structural heart training or that have trained in certain institutions,” she said. “It’s certainly on us to continue to spread out and go to the communities in need to ensure access. I think, as Dr. Giri said, there are a lot of solutions and that needs to be the focus for the next couple of years.”

Dr. Nathan reported having no relevant disclosures. Dr. Giri reported serving as a principal investigator for a research study for Boston Scientific, Inari Medical, Abbott, and Recor Medical; consulting for Boston Scientific; and serving on an advisory board for Inari Medical.

A version of this article first appeared on Medscape.com.

Being a physician gives me great privilege. However, this privilege did not start the moment I donned the white coat, but when I was born Asian American, to parents who hold advanced education degrees. It grew when our family moved to a White neighborhood and I was accepted into an elite college. For medical school and residency, I chose an academic program embedded in an urban setting that serves underprivileged minority communities. I entered psychiatry to facilitate healing. Yet as I read the headlines about people of color who had died at the hands of law enforcement, I found myself feeling overwhelmingly hopeless and numb.

In these individuals, I saw people who looked and lived just like the patients I chose to serve. But during this time, I did not see myself as the healer, but part of the system that brought pain and distress. As an Asian American, I identified with Tou Thao—the Asian American police officer involved in George Floyd’s death. In the medical community with which I identified, I found that ever-rising cases of COVID-19 were disproportionately affecting lower-income minority communities. In a polarizing world, I felt my Asian American identity prevented me from experiencing the pain and suffering Black communities faced. This was not my fight, and if it was, I was more immersed in the side that brought trauma to my patients. From a purely rational perspective, I had no right to feel sad. Intellectually, I felt unqualified to share in their pain, yet here I was, crying in my room.

An evolving transformation

As much as I wanted to take a break, training did not stop. A transformation occurred from an emerging awareness of the unique environment within which I was training and the intersection of who I knew myself to be. Serving in an urban program, I was given the opportunity for candid conversations with health professionals of color. I was humbled when Black colleagues proactively reached out to educate me about the historical context of these events and help me process them. I asked hard questions of my fellow residents who were Black, and listened to their answers and personal stories, which was difficult.

With my patients, I began to listen more intently and think about the systemic issues I had previously written off. One patient missed their appointment because public transportation was closed due to COVID-19. Another patient who was homeless was helped immensely by assistance with housing when he could no longer sleep at his place of residence. Really listening to him revealed that his street had become a common route for protests. With my therapy patient who experienced panic attacks listening to the news, I simply sat and grieved with them. I chose these interactions not because I was uniquely qualified, intelligent, or had any ability to change the trajectory of our country, but because they grew from me simply working in the context I chose and seeking the relationships I naturally sought.

How I define myself

As doctors, we accept the burden of caring for society’s ailments with the ultimate hope of celebrating triumph over the adversity of psychiatric illness. However, superseding our profession is the social system in which we live. I am part of a system that has historically caused trauma to some while benefitting others. Thus, between the calling of my practice and the country I practice in, I found a divergence. Once I accepted the truth of this system and the very personal way it affects me, my colleagues, and patients I serve, I was able to internally reconcile and rediscover hope. While I cannot change my experiences, advantages, or privilege, these facts do not change the reality that I am a citizen of the globe and human first. This realization is the silver lining of these perilous times; training among people of color who graciously included me in their experiences, and my willingness to listen and self-reflect. I now choose to define myself by what makes me similar to my patients instead of what isolates me from them. The tangible results of this deliberate step toward authenticity are renewed inspiration and joy.

For those of you who may have found yourself with no “ethnic home team” (or a desire for a new one), I leave you with this simple charge: Let your emotional reactions guide you to truth, and challenge yourself to process them with someone who doesn’t look like you. Leave your title at the door and embrace humility. You might be pleasantly surprised at the human you find when you look in the mirror.

Being a physician gives me great privilege. However, this privilege did not start the moment I donned the white coat, but when I was born Asian American, to parents who hold advanced education degrees. It grew when our family moved to a White neighborhood and I was accepted into an elite college. For medical school and residency, I chose an academic program embedded in an urban setting that serves underprivileged minority communities. I entered psychiatry to facilitate healing. Yet as I read the headlines about people of color who had died at the hands of law enforcement, I found myself feeling overwhelmingly hopeless and numb.

In these individuals, I saw people who looked and lived just like the patients I chose to serve. But during this time, I did not see myself as the healer, but part of the system that brought pain and distress. As an Asian American, I identified with Tou Thao—the Asian American police officer involved in George Floyd’s death. In the medical community with which I identified, I found that ever-rising cases of COVID-19 were disproportionately affecting lower-income minority communities. In a polarizing world, I felt my Asian American identity prevented me from experiencing the pain and suffering Black communities faced. This was not my fight, and if it was, I was more immersed in the side that brought trauma to my patients. From a purely rational perspective, I had no right to feel sad. Intellectually, I felt unqualified to share in their pain, yet here I was, crying in my room.

An evolving transformation

As much as I wanted to take a break, training did not stop. A transformation occurred from an emerging awareness of the unique environment within which I was training and the intersection of who I knew myself to be. Serving in an urban program, I was given the opportunity for candid conversations with health professionals of color. I was humbled when Black colleagues proactively reached out to educate me about the historical context of these events and help me process them. I asked hard questions of my fellow residents who were Black, and listened to their answers and personal stories, which was difficult.

With my patients, I began to listen more intently and think about the systemic issues I had previously written off. One patient missed their appointment because public transportation was closed due to COVID-19. Another patient who was homeless was helped immensely by assistance with housing when he could no longer sleep at his place of residence. Really listening to him revealed that his street had become a common route for protests. With my therapy patient who experienced panic attacks listening to the news, I simply sat and grieved with them. I chose these interactions not because I was uniquely qualified, intelligent, or had any ability to change the trajectory of our country, but because they grew from me simply working in the context I chose and seeking the relationships I naturally sought.

How I define myself

As doctors, we accept the burden of caring for society’s ailments with the ultimate hope of celebrating triumph over the adversity of psychiatric illness. However, superseding our profession is the social system in which we live. I am part of a system that has historically caused trauma to some while benefitting others. Thus, between the calling of my practice and the country I practice in, I found a divergence. Once I accepted the truth of this system and the very personal way it affects me, my colleagues, and patients I serve, I was able to internally reconcile and rediscover hope. While I cannot change my experiences, advantages, or privilege, these facts do not change the reality that I am a citizen of the globe and human first. This realization is the silver lining of these perilous times; training among people of color who graciously included me in their experiences, and my willingness to listen and self-reflect. I now choose to define myself by what makes me similar to my patients instead of what isolates me from them. The tangible results of this deliberate step toward authenticity are renewed inspiration and joy.

For those of you who may have found yourself with no “ethnic home team” (or a desire for a new one), I leave you with this simple charge: Let your emotional reactions guide you to truth, and challenge yourself to process them with someone who doesn’t look like you. Leave your title at the door and embrace humility. You might be pleasantly surprised at the human you find when you look in the mirror.

Being a physician gives me great privilege. However, this privilege did not start the moment I donned the white coat, but when I was born Asian American, to parents who hold advanced education degrees. It grew when our family moved to a White neighborhood and I was accepted into an elite college. For medical school and residency, I chose an academic program embedded in an urban setting that serves underprivileged minority communities. I entered psychiatry to facilitate healing. Yet as I read the headlines about people of color who had died at the hands of law enforcement, I found myself feeling overwhelmingly hopeless and numb.

In these individuals, I saw people who looked and lived just like the patients I chose to serve. But during this time, I did not see myself as the healer, but part of the system that brought pain and distress. As an Asian American, I identified with Tou Thao—the Asian American police officer involved in George Floyd’s death. In the medical community with which I identified, I found that ever-rising cases of COVID-19 were disproportionately affecting lower-income minority communities. In a polarizing world, I felt my Asian American identity prevented me from experiencing the pain and suffering Black communities faced. This was not my fight, and if it was, I was more immersed in the side that brought trauma to my patients. From a purely rational perspective, I had no right to feel sad. Intellectually, I felt unqualified to share in their pain, yet here I was, crying in my room.

An evolving transformation

As much as I wanted to take a break, training did not stop. A transformation occurred from an emerging awareness of the unique environment within which I was training and the intersection of who I knew myself to be. Serving in an urban program, I was given the opportunity for candid conversations with health professionals of color. I was humbled when Black colleagues proactively reached out to educate me about the historical context of these events and help me process them. I asked hard questions of my fellow residents who were Black, and listened to their answers and personal stories, which was difficult.

With my patients, I began to listen more intently and think about the systemic issues I had previously written off. One patient missed their appointment because public transportation was closed due to COVID-19. Another patient who was homeless was helped immensely by assistance with housing when he could no longer sleep at his place of residence. Really listening to him revealed that his street had become a common route for protests. With my therapy patient who experienced panic attacks listening to the news, I simply sat and grieved with them. I chose these interactions not because I was uniquely qualified, intelligent, or had any ability to change the trajectory of our country, but because they grew from me simply working in the context I chose and seeking the relationships I naturally sought.

How I define myself

As doctors, we accept the burden of caring for society’s ailments with the ultimate hope of celebrating triumph over the adversity of psychiatric illness. However, superseding our profession is the social system in which we live. I am part of a system that has historically caused trauma to some while benefitting others. Thus, between the calling of my practice and the country I practice in, I found a divergence. Once I accepted the truth of this system and the very personal way it affects me, my colleagues, and patients I serve, I was able to internally reconcile and rediscover hope. While I cannot change my experiences, advantages, or privilege, these facts do not change the reality that I am a citizen of the globe and human first. This realization is the silver lining of these perilous times; training among people of color who graciously included me in their experiences, and my willingness to listen and self-reflect. I now choose to define myself by what makes me similar to my patients instead of what isolates me from them. The tangible results of this deliberate step toward authenticity are renewed inspiration and joy.

For those of you who may have found yourself with no “ethnic home team” (or a desire for a new one), I leave you with this simple charge: Let your emotional reactions guide you to truth, and challenge yourself to process them with someone who doesn’t look like you. Leave your title at the door and embrace humility. You might be pleasantly surprised at the human you find when you look in the mirror.

Dermatologists cautioned colleagues to be aware of special hazards facing the LGBTQ community: A higher risk of skin cancer among gay men, possibly because of excess ultraviolet exposure, and acne in transgender people, who are especially vulnerable to acne because of hormone therapy.

The identities of sexual minorities “have a significant influence on many facets of health,” dermatologist Matthew Mansh, MD, of the University of Minnesota, Minneapolis, said in a presentation at the American Academy of Dermatology Virtual Meeting Experience.

In regard to skin cancer, he said, “there seems to be consistently higher rates of skin cancer and certain preventable risk behaviors like indoor tanning among sexual minority men.”

Dr. Mansh, codirector of the high-risk nonmelanoma skin cancer clinic at the University of Minnesota, highlighted a report, published in JAMA Dermatology in 2020, that used 2014-2018 U.S. survey data of over 870,000 adults to look at the association between sexual orientation and lifetime prevalence of skin cancer. The investigators found that gay and bisexual men had a higher lifetime prevalence of skin cancer compared with heterosexual men (adjusted odds ratio [aOR], 1.25; 95% confidence interval, 1.03-1.50; P = .02; and aOR, 1.46; 95% CI, 1.01-2.10; P = .04; for gay and bisexual men, respectively).

When compared with heterosexual women, risk among bisexual women was lower (aOR, 0.75; 95% CI, 0.60-0.95; P  = .02), but not among lesbian women (aOR, 1.01; 95% CI, 0.77-1.33; P = .95, respectively).

Other studies have reached similar conclusions, Dr. Mansh said, although there’s been fairly little research in this area. What could explain these differences? Factors such as smoking, age, and alcohol use affect skin cancer risk, he said, but these studies control for those variables. Instead, he noted, it’s useful to look at studies of ultraviolet exposure.

For example, he highlighted a study published in JAMA Dermatology in 2015, which examined 12-month indoor-tanning rates and skin cancer prevalence by sexual orientation, using data from California and national health interview surveys. The study found that compared with heterosexual men, “sexual minority men had higher rates of indoor tanning by roughly three- to sixfold,” said Dr. Mansh, the lead author. “And this was among respondents who were adults over age 18. People between the ages of 18 and 34 years are important from a skin cancer perspective as it’s well established that exposure to tanning beds at a younger age is most associated with an increased risk of skin cancer.”

Sexual minority men were also significantly more likely to report having skin cancer, compared with heterosexual men.

In the study, sexual minority women had about half the odds of engaging in indoor tanning compared with heterosexual women, and were less likely to report having been diagnosed with nonmelanoma skin cancer, he added.

Other studies suggest that gay and bisexual men live in neighborhoods with more indoor tanning salons and that they may spend more time in the sun outside too, he said. Some research suggests motivations for tanning include social pressure and the desire to improve appearance, he added.

Overall, “we may be able to use these data to add more appropriate screening and recommendations for these patients, which are sorely lacking in dermatology,” and to design targeted behavioral interventions, said Dr. Mansh, codirector of the dermatology gender care clinic at the University of Minnesota.

What can dermatologists do now? In an interview, dermatologist Jon Klint Peebles, MD, of the mid-Atlantic Permanente Medical Group, in Largo, Md., suggested that colleagues ask patients questions about indoor tanning frequency, the motivations for tanning, exposure to outdoor ultraviolet radiation, sunscreen use, and use of photoprotective clothing.

Hormone therapy and acne

In a related presentation at the meeting, Howa Yeung, MD, of the department of dermatology, Emory University, Atlanta, said that in transgender people, estrogen therapy can actually reduce sebum production and often improves acne, while testosterone therapy frequently has the opposite effect.

“We’ve seen some pretty tough cases of acne in transmasculine patients in my practice,” said Dr. Yeung, who highlighted a recently published study that tracked 988 transgender patients in Boston who underwent testosterone therapy. Nearly a third were diagnosed with acne, compared with 6% prior to hormone therapy, and those at the highest risk were aged 18-21.

The prevalence of acne was 25% 2 years after initiation of hormone therapy. “Acne remains a very common issue and not just at the beginning of treatment,” he said.

In 2020, Dr. Yeung and colleagues reported the results of a survey of 696 transgender patients in California and Georgia; most were treated with hormone therapy. They found that 14% of transmasculine patients reported currently having moderate to severe acne diagnosed by a physician, compared with 1% of transfeminine patients.

Dr. Yeung noted that another survey of transmasculine persons who had received testosterone found that those who had moderate to severe acne were more likely to suffer from depression and anxiety than were those who had never had acne (aOR, 2.4; 95% CI, 1.1-5.4; P = .001, for depression; and aOR, 2.7; 95% CI, 1.2-6.3; P = .002, for anxiety).

Acne treatments in transmasculine patients are complicated by the fact that hormone treatments for acne can have feminizing effects, Dr. Yeung said, adding that it’s not clear how clascoterone, a new anti-androgen topical therapy for acne, will affect them. For now, many patients will require isotretinoin for treating acne.

Dr. Peebles cautioned that with isotretinoin, “we still do not yet have solid data on the optimal dosing or duration in the context of testosterone-induced acne, as well as what individual factors may be predictive of treatment success or failure. It is also important to be aware of any planned surgical procedures, whether as part of gender-affirming care or otherwise, given that some surgeons may view isotretinoin as a barrier for some procedures, despite limited data to support this.”

Both Dr. Peebles and Dr. Yeung noted that the iPledge risk management program for isotretinoin patients who may become pregnant is problematic. “A trans man who is assigned female at birth and identifies as a man and has a uterus and ovaries must be registered as a female with reproductive potential,” Dr. Yeung said.

“While the program remains inherently discriminatory, it is important to have an honest conversation with patients about these issues in a sensitive way,” Dr. Peebles noted. “Luckily, there is substantial momentum building around modifying iPLEDGE to become more inclusive. While the mechanics are complicated and involve a variety of entities and advocacy initiatives, we are optimistic that major changes are in the pipeline.”

Dr. Mansh, Dr. Yeung, and Dr. Peebles reported no disclosures.

Dermatologists cautioned colleagues to be aware of special hazards facing the LGBTQ community: A higher risk of skin cancer among gay men, possibly because of excess ultraviolet exposure, and acne in transgender people, who are especially vulnerable to acne because of hormone therapy.

The identities of sexual minorities “have a significant influence on many facets of health,” dermatologist Matthew Mansh, MD, of the University of Minnesota, Minneapolis, said in a presentation at the American Academy of Dermatology Virtual Meeting Experience.

In regard to skin cancer, he said, “there seems to be consistently higher rates of skin cancer and certain preventable risk behaviors like indoor tanning among sexual minority men.”

Dr. Mansh, codirector of the high-risk nonmelanoma skin cancer clinic at the University of Minnesota, highlighted a report, published in JAMA Dermatology in 2020, that used 2014-2018 U.S. survey data of over 870,000 adults to look at the association between sexual orientation and lifetime prevalence of skin cancer. The investigators found that gay and bisexual men had a higher lifetime prevalence of skin cancer compared with heterosexual men (adjusted odds ratio [aOR], 1.25; 95% confidence interval, 1.03-1.50; P = .02; and aOR, 1.46; 95% CI, 1.01-2.10; P = .04; for gay and bisexual men, respectively).

When compared with heterosexual women, risk among bisexual women was lower (aOR, 0.75; 95% CI, 0.60-0.95; P  = .02), but not among lesbian women (aOR, 1.01; 95% CI, 0.77-1.33; P = .95, respectively).

Other studies have reached similar conclusions, Dr. Mansh said, although there’s been fairly little research in this area. What could explain these differences? Factors such as smoking, age, and alcohol use affect skin cancer risk, he said, but these studies control for those variables. Instead, he noted, it’s useful to look at studies of ultraviolet exposure.

For example, he highlighted a study published in JAMA Dermatology in 2015, which examined 12-month indoor-tanning rates and skin cancer prevalence by sexual orientation, using data from California and national health interview surveys. The study found that compared with heterosexual men, “sexual minority men had higher rates of indoor tanning by roughly three- to sixfold,” said Dr. Mansh, the lead author. “And this was among respondents who were adults over age 18. People between the ages of 18 and 34 years are important from a skin cancer perspective as it’s well established that exposure to tanning beds at a younger age is most associated with an increased risk of skin cancer.”

Sexual minority men were also significantly more likely to report having skin cancer, compared with heterosexual men.

In the study, sexual minority women had about half the odds of engaging in indoor tanning compared with heterosexual women, and were less likely to report having been diagnosed with nonmelanoma skin cancer, he added.

Other studies suggest that gay and bisexual men live in neighborhoods with more indoor tanning salons and that they may spend more time in the sun outside too, he said. Some research suggests motivations for tanning include social pressure and the desire to improve appearance, he added.

Overall, “we may be able to use these data to add more appropriate screening and recommendations for these patients, which are sorely lacking in dermatology,” and to design targeted behavioral interventions, said Dr. Mansh, codirector of the dermatology gender care clinic at the University of Minnesota.

What can dermatologists do now? In an interview, dermatologist Jon Klint Peebles, MD, of the mid-Atlantic Permanente Medical Group, in Largo, Md., suggested that colleagues ask patients questions about indoor tanning frequency, the motivations for tanning, exposure to outdoor ultraviolet radiation, sunscreen use, and use of photoprotective clothing.

Hormone therapy and acne

In a related presentation at the meeting, Howa Yeung, MD, of the department of dermatology, Emory University, Atlanta, said that in transgender people, estrogen therapy can actually reduce sebum production and often improves acne, while testosterone therapy frequently has the opposite effect.

“We’ve seen some pretty tough cases of acne in transmasculine patients in my practice,” said Dr. Yeung, who highlighted a recently published study that tracked 988 transgender patients in Boston who underwent testosterone therapy. Nearly a third were diagnosed with acne, compared with 6% prior to hormone therapy, and those at the highest risk were aged 18-21.

The prevalence of acne was 25% 2 years after initiation of hormone therapy. “Acne remains a very common issue and not just at the beginning of treatment,” he said.

In 2020, Dr. Yeung and colleagues reported the results of a survey of 696 transgender patients in California and Georgia; most were treated with hormone therapy. They found that 14% of transmasculine patients reported currently having moderate to severe acne diagnosed by a physician, compared with 1% of transfeminine patients.

Dr. Yeung noted that another survey of transmasculine persons who had received testosterone found that those who had moderate to severe acne were more likely to suffer from depression and anxiety than were those who had never had acne (aOR, 2.4; 95% CI, 1.1-5.4; P = .001, for depression; and aOR, 2.7; 95% CI, 1.2-6.3; P = .002, for anxiety).

Acne treatments in transmasculine patients are complicated by the fact that hormone treatments for acne can have feminizing effects, Dr. Yeung said, adding that it’s not clear how clascoterone, a new anti-androgen topical therapy for acne, will affect them. For now, many patients will require isotretinoin for treating acne.

Dr. Peebles cautioned that with isotretinoin, “we still do not yet have solid data on the optimal dosing or duration in the context of testosterone-induced acne, as well as what individual factors may be predictive of treatment success or failure. It is also important to be aware of any planned surgical procedures, whether as part of gender-affirming care or otherwise, given that some surgeons may view isotretinoin as a barrier for some procedures, despite limited data to support this.”

Both Dr. Peebles and Dr. Yeung noted that the iPledge risk management program for isotretinoin patients who may become pregnant is problematic. “A trans man who is assigned female at birth and identifies as a man and has a uterus and ovaries must be registered as a female with reproductive potential,” Dr. Yeung said.

“While the program remains inherently discriminatory, it is important to have an honest conversation with patients about these issues in a sensitive way,” Dr. Peebles noted. “Luckily, there is substantial momentum building around modifying iPLEDGE to become more inclusive. While the mechanics are complicated and involve a variety of entities and advocacy initiatives, we are optimistic that major changes are in the pipeline.”

Dr. Mansh, Dr. Yeung, and Dr. Peebles reported no disclosures.

Dermatologists cautioned colleagues to be aware of special hazards facing the LGBTQ community: A higher risk of skin cancer among gay men, possibly because of excess ultraviolet exposure, and acne in transgender people, who are especially vulnerable to acne because of hormone therapy.

The identities of sexual minorities “have a significant influence on many facets of health,” dermatologist Matthew Mansh, MD, of the University of Minnesota, Minneapolis, said in a presentation at the American Academy of Dermatology Virtual Meeting Experience.

In regard to skin cancer, he said, “there seems to be consistently higher rates of skin cancer and certain preventable risk behaviors like indoor tanning among sexual minority men.”

Dr. Mansh, codirector of the high-risk nonmelanoma skin cancer clinic at the University of Minnesota, highlighted a report, published in JAMA Dermatology in 2020, that used 2014-2018 U.S. survey data of over 870,000 adults to look at the association between sexual orientation and lifetime prevalence of skin cancer. The investigators found that gay and bisexual men had a higher lifetime prevalence of skin cancer compared with heterosexual men (adjusted odds ratio [aOR], 1.25; 95% confidence interval, 1.03-1.50; P = .02; and aOR, 1.46; 95% CI, 1.01-2.10; P = .04; for gay and bisexual men, respectively).

When compared with heterosexual women, risk among bisexual women was lower (aOR, 0.75; 95% CI, 0.60-0.95; P  = .02), but not among lesbian women (aOR, 1.01; 95% CI, 0.77-1.33; P = .95, respectively).

Other studies have reached similar conclusions, Dr. Mansh said, although there’s been fairly little research in this area. What could explain these differences? Factors such as smoking, age, and alcohol use affect skin cancer risk, he said, but these studies control for those variables. Instead, he noted, it’s useful to look at studies of ultraviolet exposure.

For example, he highlighted a study published in JAMA Dermatology in 2015, which examined 12-month indoor-tanning rates and skin cancer prevalence by sexual orientation, using data from California and national health interview surveys. The study found that compared with heterosexual men, “sexual minority men had higher rates of indoor tanning by roughly three- to sixfold,” said Dr. Mansh, the lead author. “And this was among respondents who were adults over age 18. People between the ages of 18 and 34 years are important from a skin cancer perspective as it’s well established that exposure to tanning beds at a younger age is most associated with an increased risk of skin cancer.”

Sexual minority men were also significantly more likely to report having skin cancer, compared with heterosexual men.

In the study, sexual minority women had about half the odds of engaging in indoor tanning compared with heterosexual women, and were less likely to report having been diagnosed with nonmelanoma skin cancer, he added.

Other studies suggest that gay and bisexual men live in neighborhoods with more indoor tanning salons and that they may spend more time in the sun outside too, he said. Some research suggests motivations for tanning include social pressure and the desire to improve appearance, he added.

Overall, “we may be able to use these data to add more appropriate screening and recommendations for these patients, which are sorely lacking in dermatology,” and to design targeted behavioral interventions, said Dr. Mansh, codirector of the dermatology gender care clinic at the University of Minnesota.

What can dermatologists do now? In an interview, dermatologist Jon Klint Peebles, MD, of the mid-Atlantic Permanente Medical Group, in Largo, Md., suggested that colleagues ask patients questions about indoor tanning frequency, the motivations for tanning, exposure to outdoor ultraviolet radiation, sunscreen use, and use of photoprotective clothing.

Hormone therapy and acne

In a related presentation at the meeting, Howa Yeung, MD, of the department of dermatology, Emory University, Atlanta, said that in transgender people, estrogen therapy can actually reduce sebum production and often improves acne, while testosterone therapy frequently has the opposite effect.

“We’ve seen some pretty tough cases of acne in transmasculine patients in my practice,” said Dr. Yeung, who highlighted a recently published study that tracked 988 transgender patients in Boston who underwent testosterone therapy. Nearly a third were diagnosed with acne, compared with 6% prior to hormone therapy, and those at the highest risk were aged 18-21.

The prevalence of acne was 25% 2 years after initiation of hormone therapy. “Acne remains a very common issue and not just at the beginning of treatment,” he said.

In 2020, Dr. Yeung and colleagues reported the results of a survey of 696 transgender patients in California and Georgia; most were treated with hormone therapy. They found that 14% of transmasculine patients reported currently having moderate to severe acne diagnosed by a physician, compared with 1% of transfeminine patients.

Dr. Yeung noted that another survey of transmasculine persons who had received testosterone found that those who had moderate to severe acne were more likely to suffer from depression and anxiety than were those who had never had acne (aOR, 2.4; 95% CI, 1.1-5.4; P = .001, for depression; and aOR, 2.7; 95% CI, 1.2-6.3; P = .002, for anxiety).

Acne treatments in transmasculine patients are complicated by the fact that hormone treatments for acne can have feminizing effects, Dr. Yeung said, adding that it’s not clear how clascoterone, a new anti-androgen topical therapy for acne, will affect them. For now, many patients will require isotretinoin for treating acne.

Dr. Peebles cautioned that with isotretinoin, “we still do not yet have solid data on the optimal dosing or duration in the context of testosterone-induced acne, as well as what individual factors may be predictive of treatment success or failure. It is also important to be aware of any planned surgical procedures, whether as part of gender-affirming care or otherwise, given that some surgeons may view isotretinoin as a barrier for some procedures, despite limited data to support this.”

Both Dr. Peebles and Dr. Yeung noted that the iPledge risk management program for isotretinoin patients who may become pregnant is problematic. “A trans man who is assigned female at birth and identifies as a man and has a uterus and ovaries must be registered as a female with reproductive potential,” Dr. Yeung said.

“While the program remains inherently discriminatory, it is important to have an honest conversation with patients about these issues in a sensitive way,” Dr. Peebles noted. “Luckily, there is substantial momentum building around modifying iPLEDGE to become more inclusive. While the mechanics are complicated and involve a variety of entities and advocacy initiatives, we are optimistic that major changes are in the pipeline.”

Dr. Mansh, Dr. Yeung, and Dr. Peebles reported no disclosures.