Diversity in Medicine

The more complaints of excessive force by police reported by neighborhood residents, the more likely it is that Black pregnant people living in that neighborhood will deliver preterm, according to findings from a new study presented Jan. 28 at the virtual Society for Maternal-Fetal Medicine 2021 Annual Pregnancy Meeting.

“We know there are significant racial disparities in preterm birth which aren’t fully explained by traditional risk factors, like being older, having health problems like high blood pressure, or limited income,” Alexa Freedman, PhD, a postdoctoral fellow at NorthShore University HealthSystem and Northwestern University Institute for Policy Research, Evanston, Ill., told this news organization. “This has left many wondering if there are stressors unique to Black individuals that may be involved,” which has led to past research on the association of preterm birth with neighborhood segregation and historical “redlining” practices.

Black individuals have a substantially higher rate of preterm birth, compared with all other racial and ethnic groups in the US: 13.8% of Black infants born between 2016 and 2018 were preterm, compared with 11.6% among Native Americans – the next highest group – and 9.1% among White women.

“Studies have shown that psychosocial stress contributes to preterm birth disparities, potentially through several physiologic pathways that impact pregnancy outcomes,” Dr. Freedman told attendees. “Pregnant Black individuals have been reported to experience greater psychosocial stress regardless of socioeconomic status, possibly secondary to experiences of racism and discrimination.”

Though past research has examined neighborhood disadvantage and violence as stressors potentially contributing to preterm birth, little data exist on police–community relationships or police violence and pregnancy outcomes, despite being a “particularly salient stressor for Black individuals,” Dr. Freedman said. “Among pregnant Black individuals, prenatal depression has been correlated with concern about negative interactions between youth in their community and police.” To cite one example of the prevalence of racial bias in policing, she noted that “Chicago police are almost 10 times more likely to use force when interacting with a Black individual as compared [with] a White individual.”

The researchers therefore sought to determine whether a relationship existed between preterm birth rates and complaints regarding use of excessive force by police in the same neighborhood. They compiled records on all singleton live births from one Chicago hospital between March 2008 and March 2018, excluding those who lived outside Chicago, had a missing address, listed their race as “other,” or lacked data for specific other confounders.
 

Assessing police complaints within census blocks

The researchers obtained data on police complaints in Chicago from the Invisible Institute’s Citizen Police Data Project. They focused only on complaints of excessive use of force, “such as unnecessary physical contact and unnecessary display of a weapon,” Dr. Freedman said. They considered a person exposed in the neighborhood if a complaint was reported in her census block in the year leading up to birth. During their study period, more than 6,000 complaints of excessive force were reported across an estimated 70% of the blocks.

The study population had an average age of 31 and included 59.5% White, 12% Black, 20% Hispanic, and 8.5% Asian people. Just over half the pregnancies (55%) were first-time pregnancies, and 3.3% of the population had a history of preterm birth (before 37 weeks). The researchers also gathered data to adjust for the study population’s:

• Age
• Parity (number of times the woman has given birth).
• Population size of census block.
• Exposure to a homicide on the block in the year leading up to birth.
• Socioeconomic status by block (based on a composite of median home value, median income, percentage of a high school diploma, and percentage employed).

“Those who lived in a block with an excessive force complaint were more likely to be Black, more likely to deliver preterm, and more likely to be exposed to homicide,” Dr. Freedman told attendees.

The proportion of pregnant women exposed to police complaints was 15.8%, and 10.2% lived in neighborhoods where a homicide occurred in the year leading up to birth. Within the group exposed to a homicide, 16.5% lived in a neighborhood with an excessive force complaint and 9.1% did not.

Overall, 8.1% of the population gave birth preterm. When stratified by whether or not they lived in a block with an excessive force complaint, the researchers found the proportion of preterm births was higher among those who did than those who did not (9.3% vs. 7.8%).

Both before and after adjusting for confounders, Black people were the only racial/ethnic group who had a significantly increased risk of preterm birth if they lived on a block with a complaint. They were nearly 30% more likely to deliver preterm if an excessive force complaint had been reported nearby (odds ratio, 1.29). The odds of preterm birth were slightly elevated for White people and slightly reduced for Hispanic and Asian people, but none of those associations reached significance.

In a sensitivity analysis comparing 189 Black individuals to themselves, the researchers compared those who had one preterm birth and one term birth. They found that the preterm birth was 32% more likely to occur in a year when an excessive force complaint was filed after adjusting for age and birth order (OR, 1.32; 95% confidence interval, 0.82-2.13).

“Police violence reflects just one component of structural racism,” Dr. Freedman said in an interview. “Our findings highlight the need to more thoroughly consider how these systemic and structural factors contribute to disparities in maternal and fetal health.”
 

Clinical and policy implications

The clinical implications of these findings focus on the need for obstetric clinical teams to understand patients’ stressors and to provide support and resources, according to Dr. Freedman’s mentor, Ann Borders, MD, MSc, MPH, a maternal-fetal medicine physician at NorthShore and Evanston Hospital and a clinical associate professor at the University of Chicago Pritzker School of Medicine.

“Potential strategies include training on improved listening and respectful patient-centered care, such as provided by the CDC Hear Her campaign, and consideration of universal social determinants of health screening during obstetric care,” Dr. Borders told this news organization..

Though the study included a large sample size and allowed the researchers to control for individual and neighborhood characteristics, Dr. Freedman acknowledged that census blocks may or may not correlate with the way individuals define their own neighborhoods. They also didn’t have the data to assess the quality of prenatal care or the type of preterm birth, but they are developing a qualitative study to determine the best ways of measuring exposure to police violence.

In addition, the researchers’ reliance only on formal police complaints could have underestimated prevalence of excessive force, and the study did not take into account people’s direct experience with police violence; police violence that occurs within a person’s social network; or police violence widely covered in the news. 

It wasn’t possible for the researchers to verify whether excessive force actually occurred or whether the force might have been justified, and it instead relied on the fact that someone lodged a complaint because he or she perceived the action as excessive.

Allison Bryant Mantha, MD, MPH, vice chair for Quality, Equity, and Safety at Massachusetts General Hospital in Boston and a board member of SMFM, said she was impressed with the adjustment of homicide exposure as a proxy for neighborhood crime.

“Many might assume that reports of police misconduct might be a marker for a ‘dangerous neighborhood,’ and it was thoughtful of the authors to adjust their analyses for exposure to crime to demonstrate that, even above and beyond crime, reports of police misconduct seem to be associated with adverse outcomes,” Dr. Bryant Mantha, who moderated the session, said in an interview.

Confronting this issue goes beyond what clinicians can do on their own, Dr. Bryant Mantha suggested.

“The greatest change will come with addressing the structural racism that underlies differential exposure to police misconduct in communities in the first place,” she said. “Concurrent with this, however, clinicians may consider adding in an assessment of neighborhood characteristics to include reports of police misconduct as they screen for other social determinants of health. While we do not have intervention studies to demonstrate efficacy, it is not a huge leap to imagine that recognition of this burden in individuals’ lives, plus offering ways to manage stress or seek redress, could be of benefit.”

The research was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institute on Minority Health and Health Disparities, and the Northwestern Medicine Enterprise Data Warehouse Pilot Data Program. Dr. Freedman, Dr. Borders, and Dr. Bryant Mantha have disclosed no relevant financial relationships.

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

The more complaints of excessive force by police reported by neighborhood residents, the more likely it is that Black pregnant people living in that neighborhood will deliver preterm, according to findings from a new study presented Jan. 28 at the virtual Society for Maternal-Fetal Medicine 2021 Annual Pregnancy Meeting.

“We know there are significant racial disparities in preterm birth which aren’t fully explained by traditional risk factors, like being older, having health problems like high blood pressure, or limited income,” Alexa Freedman, PhD, a postdoctoral fellow at NorthShore University HealthSystem and Northwestern University Institute for Policy Research, Evanston, Ill., told this news organization. “This has left many wondering if there are stressors unique to Black individuals that may be involved,” which has led to past research on the association of preterm birth with neighborhood segregation and historical “redlining” practices.

Black individuals have a substantially higher rate of preterm birth, compared with all other racial and ethnic groups in the US: 13.8% of Black infants born between 2016 and 2018 were preterm, compared with 11.6% among Native Americans – the next highest group – and 9.1% among White women.

“Studies have shown that psychosocial stress contributes to preterm birth disparities, potentially through several physiologic pathways that impact pregnancy outcomes,” Dr. Freedman told attendees. “Pregnant Black individuals have been reported to experience greater psychosocial stress regardless of socioeconomic status, possibly secondary to experiences of racism and discrimination.”

Though past research has examined neighborhood disadvantage and violence as stressors potentially contributing to preterm birth, little data exist on police–community relationships or police violence and pregnancy outcomes, despite being a “particularly salient stressor for Black individuals,” Dr. Freedman said. “Among pregnant Black individuals, prenatal depression has been correlated with concern about negative interactions between youth in their community and police.” To cite one example of the prevalence of racial bias in policing, she noted that “Chicago police are almost 10 times more likely to use force when interacting with a Black individual as compared [with] a White individual.”

The researchers therefore sought to determine whether a relationship existed between preterm birth rates and complaints regarding use of excessive force by police in the same neighborhood. They compiled records on all singleton live births from one Chicago hospital between March 2008 and March 2018, excluding those who lived outside Chicago, had a missing address, listed their race as “other,” or lacked data for specific other confounders.
 

Assessing police complaints within census blocks

The researchers obtained data on police complaints in Chicago from the Invisible Institute’s Citizen Police Data Project. They focused only on complaints of excessive use of force, “such as unnecessary physical contact and unnecessary display of a weapon,” Dr. Freedman said. They considered a person exposed in the neighborhood if a complaint was reported in her census block in the year leading up to birth. During their study period, more than 6,000 complaints of excessive force were reported across an estimated 70% of the blocks.

The study population had an average age of 31 and included 59.5% White, 12% Black, 20% Hispanic, and 8.5% Asian people. Just over half the pregnancies (55%) were first-time pregnancies, and 3.3% of the population had a history of preterm birth (before 37 weeks). The researchers also gathered data to adjust for the study population’s:

• Age
• Parity (number of times the woman has given birth).
• Population size of census block.
• Exposure to a homicide on the block in the year leading up to birth.
• Socioeconomic status by block (based on a composite of median home value, median income, percentage of a high school diploma, and percentage employed).

“Those who lived in a block with an excessive force complaint were more likely to be Black, more likely to deliver preterm, and more likely to be exposed to homicide,” Dr. Freedman told attendees.

The proportion of pregnant women exposed to police complaints was 15.8%, and 10.2% lived in neighborhoods where a homicide occurred in the year leading up to birth. Within the group exposed to a homicide, 16.5% lived in a neighborhood with an excessive force complaint and 9.1% did not.

Overall, 8.1% of the population gave birth preterm. When stratified by whether or not they lived in a block with an excessive force complaint, the researchers found the proportion of preterm births was higher among those who did than those who did not (9.3% vs. 7.8%).

Both before and after adjusting for confounders, Black people were the only racial/ethnic group who had a significantly increased risk of preterm birth if they lived on a block with a complaint. They were nearly 30% more likely to deliver preterm if an excessive force complaint had been reported nearby (odds ratio, 1.29). The odds of preterm birth were slightly elevated for White people and slightly reduced for Hispanic and Asian people, but none of those associations reached significance.

In a sensitivity analysis comparing 189 Black individuals to themselves, the researchers compared those who had one preterm birth and one term birth. They found that the preterm birth was 32% more likely to occur in a year when an excessive force complaint was filed after adjusting for age and birth order (OR, 1.32; 95% confidence interval, 0.82-2.13).

“Police violence reflects just one component of structural racism,” Dr. Freedman said in an interview. “Our findings highlight the need to more thoroughly consider how these systemic and structural factors contribute to disparities in maternal and fetal health.”
 

Clinical and policy implications

The clinical implications of these findings focus on the need for obstetric clinical teams to understand patients’ stressors and to provide support and resources, according to Dr. Freedman’s mentor, Ann Borders, MD, MSc, MPH, a maternal-fetal medicine physician at NorthShore and Evanston Hospital and a clinical associate professor at the University of Chicago Pritzker School of Medicine.

“Potential strategies include training on improved listening and respectful patient-centered care, such as provided by the CDC Hear Her campaign, and consideration of universal social determinants of health screening during obstetric care,” Dr. Borders told this news organization..

Though the study included a large sample size and allowed the researchers to control for individual and neighborhood characteristics, Dr. Freedman acknowledged that census blocks may or may not correlate with the way individuals define their own neighborhoods. They also didn’t have the data to assess the quality of prenatal care or the type of preterm birth, but they are developing a qualitative study to determine the best ways of measuring exposure to police violence.

In addition, the researchers’ reliance only on formal police complaints could have underestimated prevalence of excessive force, and the study did not take into account people’s direct experience with police violence; police violence that occurs within a person’s social network; or police violence widely covered in the news. 

It wasn’t possible for the researchers to verify whether excessive force actually occurred or whether the force might have been justified, and it instead relied on the fact that someone lodged a complaint because he or she perceived the action as excessive.

Allison Bryant Mantha, MD, MPH, vice chair for Quality, Equity, and Safety at Massachusetts General Hospital in Boston and a board member of SMFM, said she was impressed with the adjustment of homicide exposure as a proxy for neighborhood crime.

“Many might assume that reports of police misconduct might be a marker for a ‘dangerous neighborhood,’ and it was thoughtful of the authors to adjust their analyses for exposure to crime to demonstrate that, even above and beyond crime, reports of police misconduct seem to be associated with adverse outcomes,” Dr. Bryant Mantha, who moderated the session, said in an interview.

Confronting this issue goes beyond what clinicians can do on their own, Dr. Bryant Mantha suggested.

“The greatest change will come with addressing the structural racism that underlies differential exposure to police misconduct in communities in the first place,” she said. “Concurrent with this, however, clinicians may consider adding in an assessment of neighborhood characteristics to include reports of police misconduct as they screen for other social determinants of health. While we do not have intervention studies to demonstrate efficacy, it is not a huge leap to imagine that recognition of this burden in individuals’ lives, plus offering ways to manage stress or seek redress, could be of benefit.”

The research was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institute on Minority Health and Health Disparities, and the Northwestern Medicine Enterprise Data Warehouse Pilot Data Program. Dr. Freedman, Dr. Borders, and Dr. Bryant Mantha have disclosed no relevant financial relationships.

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

The more complaints of excessive force by police reported by neighborhood residents, the more likely it is that Black pregnant people living in that neighborhood will deliver preterm, according to findings from a new study presented Jan. 28 at the virtual Society for Maternal-Fetal Medicine 2021 Annual Pregnancy Meeting.

“We know there are significant racial disparities in preterm birth which aren’t fully explained by traditional risk factors, like being older, having health problems like high blood pressure, or limited income,” Alexa Freedman, PhD, a postdoctoral fellow at NorthShore University HealthSystem and Northwestern University Institute for Policy Research, Evanston, Ill., told this news organization. “This has left many wondering if there are stressors unique to Black individuals that may be involved,” which has led to past research on the association of preterm birth with neighborhood segregation and historical “redlining” practices.

Black individuals have a substantially higher rate of preterm birth, compared with all other racial and ethnic groups in the US: 13.8% of Black infants born between 2016 and 2018 were preterm, compared with 11.6% among Native Americans – the next highest group – and 9.1% among White women.

“Studies have shown that psychosocial stress contributes to preterm birth disparities, potentially through several physiologic pathways that impact pregnancy outcomes,” Dr. Freedman told attendees. “Pregnant Black individuals have been reported to experience greater psychosocial stress regardless of socioeconomic status, possibly secondary to experiences of racism and discrimination.”

Though past research has examined neighborhood disadvantage and violence as stressors potentially contributing to preterm birth, little data exist on police–community relationships or police violence and pregnancy outcomes, despite being a “particularly salient stressor for Black individuals,” Dr. Freedman said. “Among pregnant Black individuals, prenatal depression has been correlated with concern about negative interactions between youth in their community and police.” To cite one example of the prevalence of racial bias in policing, she noted that “Chicago police are almost 10 times more likely to use force when interacting with a Black individual as compared [with] a White individual.”

The researchers therefore sought to determine whether a relationship existed between preterm birth rates and complaints regarding use of excessive force by police in the same neighborhood. They compiled records on all singleton live births from one Chicago hospital between March 2008 and March 2018, excluding those who lived outside Chicago, had a missing address, listed their race as “other,” or lacked data for specific other confounders.
 

Assessing police complaints within census blocks

The researchers obtained data on police complaints in Chicago from the Invisible Institute’s Citizen Police Data Project. They focused only on complaints of excessive use of force, “such as unnecessary physical contact and unnecessary display of a weapon,” Dr. Freedman said. They considered a person exposed in the neighborhood if a complaint was reported in her census block in the year leading up to birth. During their study period, more than 6,000 complaints of excessive force were reported across an estimated 70% of the blocks.

The study population had an average age of 31 and included 59.5% White, 12% Black, 20% Hispanic, and 8.5% Asian people. Just over half the pregnancies (55%) were first-time pregnancies, and 3.3% of the population had a history of preterm birth (before 37 weeks). The researchers also gathered data to adjust for the study population’s:

• Age
• Parity (number of times the woman has given birth).
• Population size of census block.
• Exposure to a homicide on the block in the year leading up to birth.
• Socioeconomic status by block (based on a composite of median home value, median income, percentage of a high school diploma, and percentage employed).

“Those who lived in a block with an excessive force complaint were more likely to be Black, more likely to deliver preterm, and more likely to be exposed to homicide,” Dr. Freedman told attendees.

The proportion of pregnant women exposed to police complaints was 15.8%, and 10.2% lived in neighborhoods where a homicide occurred in the year leading up to birth. Within the group exposed to a homicide, 16.5% lived in a neighborhood with an excessive force complaint and 9.1% did not.

Overall, 8.1% of the population gave birth preterm. When stratified by whether or not they lived in a block with an excessive force complaint, the researchers found the proportion of preterm births was higher among those who did than those who did not (9.3% vs. 7.8%).

Both before and after adjusting for confounders, Black people were the only racial/ethnic group who had a significantly increased risk of preterm birth if they lived on a block with a complaint. They were nearly 30% more likely to deliver preterm if an excessive force complaint had been reported nearby (odds ratio, 1.29). The odds of preterm birth were slightly elevated for White people and slightly reduced for Hispanic and Asian people, but none of those associations reached significance.

In a sensitivity analysis comparing 189 Black individuals to themselves, the researchers compared those who had one preterm birth and one term birth. They found that the preterm birth was 32% more likely to occur in a year when an excessive force complaint was filed after adjusting for age and birth order (OR, 1.32; 95% confidence interval, 0.82-2.13).

“Police violence reflects just one component of structural racism,” Dr. Freedman said in an interview. “Our findings highlight the need to more thoroughly consider how these systemic and structural factors contribute to disparities in maternal and fetal health.”
 

Clinical and policy implications

The clinical implications of these findings focus on the need for obstetric clinical teams to understand patients’ stressors and to provide support and resources, according to Dr. Freedman’s mentor, Ann Borders, MD, MSc, MPH, a maternal-fetal medicine physician at NorthShore and Evanston Hospital and a clinical associate professor at the University of Chicago Pritzker School of Medicine.

“Potential strategies include training on improved listening and respectful patient-centered care, such as provided by the CDC Hear Her campaign, and consideration of universal social determinants of health screening during obstetric care,” Dr. Borders told this news organization..

Though the study included a large sample size and allowed the researchers to control for individual and neighborhood characteristics, Dr. Freedman acknowledged that census blocks may or may not correlate with the way individuals define their own neighborhoods. They also didn’t have the data to assess the quality of prenatal care or the type of preterm birth, but they are developing a qualitative study to determine the best ways of measuring exposure to police violence.

In addition, the researchers’ reliance only on formal police complaints could have underestimated prevalence of excessive force, and the study did not take into account people’s direct experience with police violence; police violence that occurs within a person’s social network; or police violence widely covered in the news. 

It wasn’t possible for the researchers to verify whether excessive force actually occurred or whether the force might have been justified, and it instead relied on the fact that someone lodged a complaint because he or she perceived the action as excessive.

Allison Bryant Mantha, MD, MPH, vice chair for Quality, Equity, and Safety at Massachusetts General Hospital in Boston and a board member of SMFM, said she was impressed with the adjustment of homicide exposure as a proxy for neighborhood crime.

“Many might assume that reports of police misconduct might be a marker for a ‘dangerous neighborhood,’ and it was thoughtful of the authors to adjust their analyses for exposure to crime to demonstrate that, even above and beyond crime, reports of police misconduct seem to be associated with adverse outcomes,” Dr. Bryant Mantha, who moderated the session, said in an interview.

Confronting this issue goes beyond what clinicians can do on their own, Dr. Bryant Mantha suggested.

“The greatest change will come with addressing the structural racism that underlies differential exposure to police misconduct in communities in the first place,” she said. “Concurrent with this, however, clinicians may consider adding in an assessment of neighborhood characteristics to include reports of police misconduct as they screen for other social determinants of health. While we do not have intervention studies to demonstrate efficacy, it is not a huge leap to imagine that recognition of this burden in individuals’ lives, plus offering ways to manage stress or seek redress, could be of benefit.”

The research was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institute on Minority Health and Health Disparities, and the Northwestern Medicine Enterprise Data Warehouse Pilot Data Program. Dr. Freedman, Dr. Borders, and Dr. Bryant Mantha have disclosed no relevant financial relationships.

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

An analysis of data from the U.S. military suggests that the maternal morbidity disparities between Black and White women cannot be attributed solely to differences in access to care and socioeconomics.

Even in the U.S. military health care system, where all service members have universal access to the same facilities and providers, researchers found substantial racial disparities in cesarean deliveries, maternal ICU admission, and overall severe maternal morbidity and mortality between Black patients and White patients, according to findings from a new study presented Jan. 28, 2021, at a meeting sponsored by the Society for Maternal-Fetal Medicine.

“This was surprising given some of the driving theories behind maternal race disparities encountered in this country, such as access to care and socioeconomic status, are controlled for in this health care system,” Capt. Jameaka Hamilton, MD, who presented the research, said in an interview. “Our findings indicate that there are likely additional factors at play which impact the obstetrical outcomes of women based upon their race, including systems-based barriers to accessing the military health care system which contribute to health care disparities, or in systemic or implicit biases which occur within our health care delivery.”

Plenty of recent research has documented the rise in maternal morbidity and mortality in the United States and the considerable racial disparities within those statistics. Black women are twice as likely to suffer morbidity and three to four times more likely to die in childbirth, compared with White women, Dr. Hamilton, an ob.gyn. from the San Antonio Uniformed Services Health Education Consortium at Ft. Sam Houston in San Antonio, Texas, reminded attendees. So far, much of this disparity has been attributed to social determinants of health.

Military retirees, active-duty personnel, and dependents, however, have equal access to federal health insurance and care at military health care facilities, or at covered civilian facilities where needed. Hence the researchers’ hypothesis that the military medical system would not show the same disparities by race that are seen in civilian populations.

The researchers analyzed maternal morbidity data from the Neonatal Perinatal Information Center from April 2018 to March 2019. The retrospective study included data from 13 military treatment facilities that had more than 1,000 deliveries per year. In addition to statistics on cesarean delivery and adult ICU admission, the researchers compared numbers on overall severe maternal morbidity based on the indicators defined by the Centers for Disease Control and Prevention.

The 15,305 deliveries included 23% Black patients and 77% White patients from the Air Force, Army, and Navy branches.

The cesarean delivery rate ranged from 19.4% to 35.5%. ICU admissions totaled 38 women, 190 women had postpartum hemorrhage, and 282 women experienced severe maternal morbidity. All three measures revealed racial disparities:

• Overall severe maternal morbidity occurred in 2.66% of Black women and 1.66% of White women (P =.0001).
• ICU admission occurred in 0.49% of Black women and 0.18% of White women (P =.0026).
• 31.68% of Black women had a cesarean delivery, compared with 23.58% of White women (P <.0001).

After excluding cases with blood transfusions, Black women were twice as likely to have severe maternal morbidity (0.64% vs. 0.32%). There were no significant differences in postpartum hemorrhage rates between Black and White women, but this analysis was limited by the small overall numbers of postpartum hemorrhage.

Among the study’s limitations were the inability to stratify patients by retiree, active duty, or dependent status, and the lack of data on preeclampsia rates, maternal age, obesity, or other preexisting conditions. In addition, the initial dataset included 61% of patients who reported their race as “other” than Black or White, limiting the number of patients whose data could be analyzed. Since low-volume hospitals were excluded, the outcomes could be skewed if lower-volume facilities are more likely to care for more complex cases, Dr. Hamilton added.

Allison Bryant Mantha, MD, MPH, vice chair for quality, equity, and safety in the ob.gyn. department at Massachusetts General Hospital, Boston, praised Dr. Hamilton’s work for revealing that differential access – though still problematic – cannot fully explain inequities between Black women and other women.

“The findings are not shocking given that what underlies some of these inequities – namely structural and institutional racism, and differential treatment within the system – are not exclusive to civilian health care settings,” Dr. Bryant Mantha, who moderated the session, said in an interview. “That said, doing the work to demonstrate this is extremely valuable.”

Although the causes of these disparities are systemic, Dr. Hamilton said individual providers can play a role in addressing them.

“There can certainly be more done to address this dangerous trend at the provider, hospital/institution, and national level,” she said. I think we as providers should continue to self-reflect and address our own biases. Hospitals and institutions should continue to develop policies that draw attention health care disparities.”

Completely removing these inequalities, however, will require confronting the racism embedded in U.S. health care at all levels, Dr. Bryant Mantha suggested.

“Ultimately, moving to an antiracist health care system – and criminal justice system, educational system, political system, etc. – and dismantling the existing structural racism in policies and practices will be needed to drive this change,” Dr. Bryant Mantha said. “Individual clinicians can use their voices to advocate for these changes in their health systems, communities, and states. Awareness of these inequities is critical, as is a sense of collective efficacy that we can, indeed, change the status quo.”

Dr. Hamilton and Dr. Bryant Mantha reported no disclosures.

An analysis of data from the U.S. military suggests that the maternal morbidity disparities between Black and White women cannot be attributed solely to differences in access to care and socioeconomics.

Even in the U.S. military health care system, where all service members have universal access to the same facilities and providers, researchers found substantial racial disparities in cesarean deliveries, maternal ICU admission, and overall severe maternal morbidity and mortality between Black patients and White patients, according to findings from a new study presented Jan. 28, 2021, at a meeting sponsored by the Society for Maternal-Fetal Medicine.

“This was surprising given some of the driving theories behind maternal race disparities encountered in this country, such as access to care and socioeconomic status, are controlled for in this health care system,” Capt. Jameaka Hamilton, MD, who presented the research, said in an interview. “Our findings indicate that there are likely additional factors at play which impact the obstetrical outcomes of women based upon their race, including systems-based barriers to accessing the military health care system which contribute to health care disparities, or in systemic or implicit biases which occur within our health care delivery.”

Plenty of recent research has documented the rise in maternal morbidity and mortality in the United States and the considerable racial disparities within those statistics. Black women are twice as likely to suffer morbidity and three to four times more likely to die in childbirth, compared with White women, Dr. Hamilton, an ob.gyn. from the San Antonio Uniformed Services Health Education Consortium at Ft. Sam Houston in San Antonio, Texas, reminded attendees. So far, much of this disparity has been attributed to social determinants of health.

Military retirees, active-duty personnel, and dependents, however, have equal access to federal health insurance and care at military health care facilities, or at covered civilian facilities where needed. Hence the researchers’ hypothesis that the military medical system would not show the same disparities by race that are seen in civilian populations.

The researchers analyzed maternal morbidity data from the Neonatal Perinatal Information Center from April 2018 to March 2019. The retrospective study included data from 13 military treatment facilities that had more than 1,000 deliveries per year. In addition to statistics on cesarean delivery and adult ICU admission, the researchers compared numbers on overall severe maternal morbidity based on the indicators defined by the Centers for Disease Control and Prevention.

The 15,305 deliveries included 23% Black patients and 77% White patients from the Air Force, Army, and Navy branches.

The cesarean delivery rate ranged from 19.4% to 35.5%. ICU admissions totaled 38 women, 190 women had postpartum hemorrhage, and 282 women experienced severe maternal morbidity. All three measures revealed racial disparities:

• Overall severe maternal morbidity occurred in 2.66% of Black women and 1.66% of White women (P =.0001).
• ICU admission occurred in 0.49% of Black women and 0.18% of White women (P =.0026).
• 31.68% of Black women had a cesarean delivery, compared with 23.58% of White women (P <.0001).

After excluding cases with blood transfusions, Black women were twice as likely to have severe maternal morbidity (0.64% vs. 0.32%). There were no significant differences in postpartum hemorrhage rates between Black and White women, but this analysis was limited by the small overall numbers of postpartum hemorrhage.

Among the study’s limitations were the inability to stratify patients by retiree, active duty, or dependent status, and the lack of data on preeclampsia rates, maternal age, obesity, or other preexisting conditions. In addition, the initial dataset included 61% of patients who reported their race as “other” than Black or White, limiting the number of patients whose data could be analyzed. Since low-volume hospitals were excluded, the outcomes could be skewed if lower-volume facilities are more likely to care for more complex cases, Dr. Hamilton added.

Allison Bryant Mantha, MD, MPH, vice chair for quality, equity, and safety in the ob.gyn. department at Massachusetts General Hospital, Boston, praised Dr. Hamilton’s work for revealing that differential access – though still problematic – cannot fully explain inequities between Black women and other women.

“The findings are not shocking given that what underlies some of these inequities – namely structural and institutional racism, and differential treatment within the system – are not exclusive to civilian health care settings,” Dr. Bryant Mantha, who moderated the session, said in an interview. “That said, doing the work to demonstrate this is extremely valuable.”

Although the causes of these disparities are systemic, Dr. Hamilton said individual providers can play a role in addressing them.

“There can certainly be more done to address this dangerous trend at the provider, hospital/institution, and national level,” she said. I think we as providers should continue to self-reflect and address our own biases. Hospitals and institutions should continue to develop policies that draw attention health care disparities.”

Completely removing these inequalities, however, will require confronting the racism embedded in U.S. health care at all levels, Dr. Bryant Mantha suggested.

“Ultimately, moving to an antiracist health care system – and criminal justice system, educational system, political system, etc. – and dismantling the existing structural racism in policies and practices will be needed to drive this change,” Dr. Bryant Mantha said. “Individual clinicians can use their voices to advocate for these changes in their health systems, communities, and states. Awareness of these inequities is critical, as is a sense of collective efficacy that we can, indeed, change the status quo.”

Dr. Hamilton and Dr. Bryant Mantha reported no disclosures.

An analysis of data from the U.S. military suggests that the maternal morbidity disparities between Black and White women cannot be attributed solely to differences in access to care and socioeconomics.

Even in the U.S. military health care system, where all service members have universal access to the same facilities and providers, researchers found substantial racial disparities in cesarean deliveries, maternal ICU admission, and overall severe maternal morbidity and mortality between Black patients and White patients, according to findings from a new study presented Jan. 28, 2021, at a meeting sponsored by the Society for Maternal-Fetal Medicine.

“This was surprising given some of the driving theories behind maternal race disparities encountered in this country, such as access to care and socioeconomic status, are controlled for in this health care system,” Capt. Jameaka Hamilton, MD, who presented the research, said in an interview. “Our findings indicate that there are likely additional factors at play which impact the obstetrical outcomes of women based upon their race, including systems-based barriers to accessing the military health care system which contribute to health care disparities, or in systemic or implicit biases which occur within our health care delivery.”

Plenty of recent research has documented the rise in maternal morbidity and mortality in the United States and the considerable racial disparities within those statistics. Black women are twice as likely to suffer morbidity and three to four times more likely to die in childbirth, compared with White women, Dr. Hamilton, an ob.gyn. from the San Antonio Uniformed Services Health Education Consortium at Ft. Sam Houston in San Antonio, Texas, reminded attendees. So far, much of this disparity has been attributed to social determinants of health.

Military retirees, active-duty personnel, and dependents, however, have equal access to federal health insurance and care at military health care facilities, or at covered civilian facilities where needed. Hence the researchers’ hypothesis that the military medical system would not show the same disparities by race that are seen in civilian populations.

The researchers analyzed maternal morbidity data from the Neonatal Perinatal Information Center from April 2018 to March 2019. The retrospective study included data from 13 military treatment facilities that had more than 1,000 deliveries per year. In addition to statistics on cesarean delivery and adult ICU admission, the researchers compared numbers on overall severe maternal morbidity based on the indicators defined by the Centers for Disease Control and Prevention.

The 15,305 deliveries included 23% Black patients and 77% White patients from the Air Force, Army, and Navy branches.

The cesarean delivery rate ranged from 19.4% to 35.5%. ICU admissions totaled 38 women, 190 women had postpartum hemorrhage, and 282 women experienced severe maternal morbidity. All three measures revealed racial disparities:

• Overall severe maternal morbidity occurred in 2.66% of Black women and 1.66% of White women (P =.0001).
• ICU admission occurred in 0.49% of Black women and 0.18% of White women (P =.0026).
• 31.68% of Black women had a cesarean delivery, compared with 23.58% of White women (P <.0001).

After excluding cases with blood transfusions, Black women were twice as likely to have severe maternal morbidity (0.64% vs. 0.32%). There were no significant differences in postpartum hemorrhage rates between Black and White women, but this analysis was limited by the small overall numbers of postpartum hemorrhage.

Among the study’s limitations were the inability to stratify patients by retiree, active duty, or dependent status, and the lack of data on preeclampsia rates, maternal age, obesity, or other preexisting conditions. In addition, the initial dataset included 61% of patients who reported their race as “other” than Black or White, limiting the number of patients whose data could be analyzed. Since low-volume hospitals were excluded, the outcomes could be skewed if lower-volume facilities are more likely to care for more complex cases, Dr. Hamilton added.

Allison Bryant Mantha, MD, MPH, vice chair for quality, equity, and safety in the ob.gyn. department at Massachusetts General Hospital, Boston, praised Dr. Hamilton’s work for revealing that differential access – though still problematic – cannot fully explain inequities between Black women and other women.

“The findings are not shocking given that what underlies some of these inequities – namely structural and institutional racism, and differential treatment within the system – are not exclusive to civilian health care settings,” Dr. Bryant Mantha, who moderated the session, said in an interview. “That said, doing the work to demonstrate this is extremely valuable.”

Although the causes of these disparities are systemic, Dr. Hamilton said individual providers can play a role in addressing them.

“There can certainly be more done to address this dangerous trend at the provider, hospital/institution, and national level,” she said. I think we as providers should continue to self-reflect and address our own biases. Hospitals and institutions should continue to develop policies that draw attention health care disparities.”

Completely removing these inequalities, however, will require confronting the racism embedded in U.S. health care at all levels, Dr. Bryant Mantha suggested.

“Ultimately, moving to an antiracist health care system – and criminal justice system, educational system, political system, etc. – and dismantling the existing structural racism in policies and practices will be needed to drive this change,” Dr. Bryant Mantha said. “Individual clinicians can use their voices to advocate for these changes in their health systems, communities, and states. Awareness of these inequities is critical, as is a sense of collective efficacy that we can, indeed, change the status quo.”

Dr. Hamilton and Dr. Bryant Mantha reported no disclosures.

New research suggests that proposed lung cancer screening guidelines could inadvertently increase racial and ethnic disparities, but adding in a risk prediction model could reduce some of these disparities by identifying people with high predicted benefit, regardless of race or ethnicity.

The draft United States Preventive Services Task Force (USPSTF) 2020 guidelines recommend annual lung cancer screening for individuals aged 50-80 who currently smoke or quit in the last 15 years, and who have a smoking history equivalent to at least one pack of cigarettes per day for 20 years or more.

This expands the age range and smoking history requirement compared to the 2013 USPSTF recommendations in an attempt to partially ameliorate racial disparities in screening eligibility. The 2013 guidelines recommend screening ever-smokers aged 55-80 with 30 or more pack-years and 15 or fewer quit-years.

However, neither the 2013 nor the 2020 USPSTF recommendations consider the higher risk of lung cancer and younger ages at diagnosis among African Americans, despite their smoking less than Whites, according to Rebecca Landy, PhD, of the National Cancer Institute in Bethesda, Md.

“For the same age and smoking history as Whites, minorities have substantially different lung cancer risk,” Dr. Landy said. “Incorporating individualized prediction models into USPSTF guidelines may reduce racial/ethnic disparities in lung cancer screening eligibility.”

Dr. Landy and colleagues set out to test that theory, and she presented the results at the 2020 World Congress on Lung Cancer (Abstract 3564), which was rescheduled for January 2021. The results were published in the Journal of the National Cancer Institute.
 

Study details

Dr. Landy and colleagues modeled the performance of National Lung Screening Trial–like screening (three annual CT screens, 5 years of follow-up) among three cohorts of ever-smokers aged 50-80 using the 2015 National Health Interview Survey.

One group was eligible by USPSTF 2013 guidelines, another by draft USPSTF 2020 guidelines, and yet another by augmenting the USPSTF 2020 guidelines using risk prediction to include individuals with 12 or more days of life gained according to the Life-Years From Screening–CT (LYFS-CT) model.

“Among each race/ethnicity, we calculated the number eligible for screening, proportion of preventable lung cancer deaths prevented, proportion of gainable life-years gained, and screening effectiveness, as well as the relative disparities in lung cancer deaths prevented and life-years gained,” Dr. Landy said.
 

Results

Under the 2013 guidelines, 8 million ever-smokers were eligible. The disparities in lung cancer death sensitivity, compared to Whites, were 15% for African Americans, 15% for Asian Americans, and 24% for Hispanic Americans. Disparities for life-year gained sensitivity were 15%, 13%, and 24%, respectively.

Under the 2020 draft guidelines, 14.5 million ever-smokers were eligible, but racial/ethnic disparities persisted. Disparities in lung cancer death sensitivity were 13% for African Americans, 19% for Asian Americans, and 27% for Hispanic Americans. Disparities for life-year gained sensitivity were 16%, 19%, and 27%, respectively.

Using the LYFS-CT predictive-risk model added an additional 3.5 million people and “nearly eliminated” disparities for African Americans, Dr. Landy noted. However, disparities persisted for Asian Americans and Hispanic Americans.

Disparities in lung cancer death sensitivity were 0% for African Americans, 19% for Asian Americans, and 23% for Hispanic Americans. Disparities for life-year gained sensitivity were 1%, 19%, and 24%, respectively.
 

More and widening disparity

The results showed that augmenting USPSTF criteria to include high-benefit people selected significantly more African Americans than Whites and could therefore reduce or even eliminate disparities between Whites and African Americans.

“The 2020 USPSTF draft recommendations would make 6.5 million more people eligible to be screened, in addition to the 8 million from the 2013 criteria,” said Gerard Silvestri, MD, of the Medical University of South Carolina, Charleston, who was not involved in this study.

“But there will be more White people than African American people added, and the disparity between them may widen. Using the risk prediction model outlined in this well-researched study could close the gap in disparity. It’s important to identify individual risk and life expectancy.”

Dr. Silvestri pointed out that, compared to Whites, African Americans develop lung cancer at an earlier age with fewer pack-years history of smoking and have worse outcomes.

“We can’t just focus on one aspect of disparity,” he said. “African Americans are much less likely to be insured or to identify a primary care provider for integrated care. We know that screening works. The 2020 USPSTF draft recommendations will enlarge the pool of eligible African Americans and reduce disparities if the other part of the equation holds; that is, they get access to care and screening.”

This study was funded by the National Institutes of Health/National Cancer Institute. Dr. Landy and Dr. Silvestri have no disclosures.

New research suggests that proposed lung cancer screening guidelines could inadvertently increase racial and ethnic disparities, but adding in a risk prediction model could reduce some of these disparities by identifying people with high predicted benefit, regardless of race or ethnicity.

The draft United States Preventive Services Task Force (USPSTF) 2020 guidelines recommend annual lung cancer screening for individuals aged 50-80 who currently smoke or quit in the last 15 years, and who have a smoking history equivalent to at least one pack of cigarettes per day for 20 years or more.

This expands the age range and smoking history requirement compared to the 2013 USPSTF recommendations in an attempt to partially ameliorate racial disparities in screening eligibility. The 2013 guidelines recommend screening ever-smokers aged 55-80 with 30 or more pack-years and 15 or fewer quit-years.

However, neither the 2013 nor the 2020 USPSTF recommendations consider the higher risk of lung cancer and younger ages at diagnosis among African Americans, despite their smoking less than Whites, according to Rebecca Landy, PhD, of the National Cancer Institute in Bethesda, Md.

“For the same age and smoking history as Whites, minorities have substantially different lung cancer risk,” Dr. Landy said. “Incorporating individualized prediction models into USPSTF guidelines may reduce racial/ethnic disparities in lung cancer screening eligibility.”

Dr. Landy and colleagues set out to test that theory, and she presented the results at the 2020 World Congress on Lung Cancer (Abstract 3564), which was rescheduled for January 2021. The results were published in the Journal of the National Cancer Institute.
 

Study details

Dr. Landy and colleagues modeled the performance of National Lung Screening Trial–like screening (three annual CT screens, 5 years of follow-up) among three cohorts of ever-smokers aged 50-80 using the 2015 National Health Interview Survey.

One group was eligible by USPSTF 2013 guidelines, another by draft USPSTF 2020 guidelines, and yet another by augmenting the USPSTF 2020 guidelines using risk prediction to include individuals with 12 or more days of life gained according to the Life-Years From Screening–CT (LYFS-CT) model.

“Among each race/ethnicity, we calculated the number eligible for screening, proportion of preventable lung cancer deaths prevented, proportion of gainable life-years gained, and screening effectiveness, as well as the relative disparities in lung cancer deaths prevented and life-years gained,” Dr. Landy said.
 

Results

Under the 2013 guidelines, 8 million ever-smokers were eligible. The disparities in lung cancer death sensitivity, compared to Whites, were 15% for African Americans, 15% for Asian Americans, and 24% for Hispanic Americans. Disparities for life-year gained sensitivity were 15%, 13%, and 24%, respectively.

Under the 2020 draft guidelines, 14.5 million ever-smokers were eligible, but racial/ethnic disparities persisted. Disparities in lung cancer death sensitivity were 13% for African Americans, 19% for Asian Americans, and 27% for Hispanic Americans. Disparities for life-year gained sensitivity were 16%, 19%, and 27%, respectively.

Using the LYFS-CT predictive-risk model added an additional 3.5 million people and “nearly eliminated” disparities for African Americans, Dr. Landy noted. However, disparities persisted for Asian Americans and Hispanic Americans.

Disparities in lung cancer death sensitivity were 0% for African Americans, 19% for Asian Americans, and 23% for Hispanic Americans. Disparities for life-year gained sensitivity were 1%, 19%, and 24%, respectively.
 

More and widening disparity

The results showed that augmenting USPSTF criteria to include high-benefit people selected significantly more African Americans than Whites and could therefore reduce or even eliminate disparities between Whites and African Americans.

“The 2020 USPSTF draft recommendations would make 6.5 million more people eligible to be screened, in addition to the 8 million from the 2013 criteria,” said Gerard Silvestri, MD, of the Medical University of South Carolina, Charleston, who was not involved in this study.

“But there will be more White people than African American people added, and the disparity between them may widen. Using the risk prediction model outlined in this well-researched study could close the gap in disparity. It’s important to identify individual risk and life expectancy.”

Dr. Silvestri pointed out that, compared to Whites, African Americans develop lung cancer at an earlier age with fewer pack-years history of smoking and have worse outcomes.

“We can’t just focus on one aspect of disparity,” he said. “African Americans are much less likely to be insured or to identify a primary care provider for integrated care. We know that screening works. The 2020 USPSTF draft recommendations will enlarge the pool of eligible African Americans and reduce disparities if the other part of the equation holds; that is, they get access to care and screening.”

This study was funded by the National Institutes of Health/National Cancer Institute. Dr. Landy and Dr. Silvestri have no disclosures.

New research suggests that proposed lung cancer screening guidelines could inadvertently increase racial and ethnic disparities, but adding in a risk prediction model could reduce some of these disparities by identifying people with high predicted benefit, regardless of race or ethnicity.

The draft United States Preventive Services Task Force (USPSTF) 2020 guidelines recommend annual lung cancer screening for individuals aged 50-80 who currently smoke or quit in the last 15 years, and who have a smoking history equivalent to at least one pack of cigarettes per day for 20 years or more.

This expands the age range and smoking history requirement compared to the 2013 USPSTF recommendations in an attempt to partially ameliorate racial disparities in screening eligibility. The 2013 guidelines recommend screening ever-smokers aged 55-80 with 30 or more pack-years and 15 or fewer quit-years.

However, neither the 2013 nor the 2020 USPSTF recommendations consider the higher risk of lung cancer and younger ages at diagnosis among African Americans, despite their smoking less than Whites, according to Rebecca Landy, PhD, of the National Cancer Institute in Bethesda, Md.

“For the same age and smoking history as Whites, minorities have substantially different lung cancer risk,” Dr. Landy said. “Incorporating individualized prediction models into USPSTF guidelines may reduce racial/ethnic disparities in lung cancer screening eligibility.”

Dr. Landy and colleagues set out to test that theory, and she presented the results at the 2020 World Congress on Lung Cancer (Abstract 3564), which was rescheduled for January 2021. The results were published in the Journal of the National Cancer Institute.
 

Study details

Dr. Landy and colleagues modeled the performance of National Lung Screening Trial–like screening (three annual CT screens, 5 years of follow-up) among three cohorts of ever-smokers aged 50-80 using the 2015 National Health Interview Survey.

One group was eligible by USPSTF 2013 guidelines, another by draft USPSTF 2020 guidelines, and yet another by augmenting the USPSTF 2020 guidelines using risk prediction to include individuals with 12 or more days of life gained according to the Life-Years From Screening–CT (LYFS-CT) model.

“Among each race/ethnicity, we calculated the number eligible for screening, proportion of preventable lung cancer deaths prevented, proportion of gainable life-years gained, and screening effectiveness, as well as the relative disparities in lung cancer deaths prevented and life-years gained,” Dr. Landy said.
 

Results

Under the 2013 guidelines, 8 million ever-smokers were eligible. The disparities in lung cancer death sensitivity, compared to Whites, were 15% for African Americans, 15% for Asian Americans, and 24% for Hispanic Americans. Disparities for life-year gained sensitivity were 15%, 13%, and 24%, respectively.

Under the 2020 draft guidelines, 14.5 million ever-smokers were eligible, but racial/ethnic disparities persisted. Disparities in lung cancer death sensitivity were 13% for African Americans, 19% for Asian Americans, and 27% for Hispanic Americans. Disparities for life-year gained sensitivity were 16%, 19%, and 27%, respectively.

Using the LYFS-CT predictive-risk model added an additional 3.5 million people and “nearly eliminated” disparities for African Americans, Dr. Landy noted. However, disparities persisted for Asian Americans and Hispanic Americans.

Disparities in lung cancer death sensitivity were 0% for African Americans, 19% for Asian Americans, and 23% for Hispanic Americans. Disparities for life-year gained sensitivity were 1%, 19%, and 24%, respectively.
 

More and widening disparity

The results showed that augmenting USPSTF criteria to include high-benefit people selected significantly more African Americans than Whites and could therefore reduce or even eliminate disparities between Whites and African Americans.

“The 2020 USPSTF draft recommendations would make 6.5 million more people eligible to be screened, in addition to the 8 million from the 2013 criteria,” said Gerard Silvestri, MD, of the Medical University of South Carolina, Charleston, who was not involved in this study.

“But there will be more White people than African American people added, and the disparity between them may widen. Using the risk prediction model outlined in this well-researched study could close the gap in disparity. It’s important to identify individual risk and life expectancy.”

Dr. Silvestri pointed out that, compared to Whites, African Americans develop lung cancer at an earlier age with fewer pack-years history of smoking and have worse outcomes.

“We can’t just focus on one aspect of disparity,” he said. “African Americans are much less likely to be insured or to identify a primary care provider for integrated care. We know that screening works. The 2020 USPSTF draft recommendations will enlarge the pool of eligible African Americans and reduce disparities if the other part of the equation holds; that is, they get access to care and screening.”

This study was funded by the National Institutes of Health/National Cancer Institute. Dr. Landy and Dr. Silvestri have no disclosures.

Use of a semiautonomous algorithm to initiate treatment for hypertension emergencies in pregnancy significantly increased the number of individuals treated promptly, based on data from 959 obstetric patients.

Data show poor compliance with the current American College of Obstetricians and Gynecologists recommendations for treatment of acute severe hypertension with no more than 30-60 minutes’ delay; low compliance may be caused by “multiple factors including lack of intravenous access, inadequate health care practitioner or nursing availability, and implicit racial biases,” wrote Courtney Martin, DO, of Loma Linda (Calif.) University School of Medicine and colleagues.

Semiautomated treatment algorithms have been used to improve timely treatment of conditions including myocardial infarction, heart failure, acute stroke, and asthma, but their use in obstetrics to date has been limited, the researchers noted.

In a retrospective cohort study published in Obstetrics & Gynecology, the researchers identified pregnant and postpartum women treated for severe hypertension at a single center between January 2017 and March 2020. A semiautonomous treatment algorithm was implemented between May 2018 and March 2019. The algorithm included vital sign monitoring, blood pressure thresholds for diagnosis of severe hypertension, and automated order sets for recommended first-line antihypertensive therapy. The primary outcomes were treatment with antihypertensive therapy within 15, 30, and 60 minutes of diagnosis. “Severe hypertension was defined as systolic blood pressure 160 mm Hg or higher or diastolic blood pressure 110 mm Hg or higher,” the researchers said.

The study population was divided into three groups; a preimplementation group (373 patients) managed between January 2017 and April 2018, a during-implementation group (334 patients) managed between May 2018 and March 2019, and a postimplementation group (252 patients) managed between April 2019 and March 2020. Patient demographics were similar among all three groups.
 

Timely treatment improves with algorithm

Overall, treatment of severe hypertension within 15 minutes of diagnosis was 36.5% preimplementation, 45.8% during implementation, and 55.6% postimplementation. Severe hypertension treatment within 30 minutes of diagnosis was 65.9% preimplementation, 77.8% during implementation, and 79.0% post implementation. Differences were significant between pre- and post implementation for 15 minutes and 30 minutes, but no significant differences occurred in the patients treated within 60 minutes before and after implementation of the algorithm.

The study findings were limited by several factors, including the inability to separate peer-to-peer education and other training from the impact of the algorithm, as well as a lack of data on the effect of the algorithm on maternal or neonatal outcomes, the researchers noted.

However, the results support the potential of a semiautonomous algorithm to significantly improve adherence to the recommended treatment guidelines for severe hypertension in pregnancy and post partum, they said. Given the expected increase in hypertensive disorders in pregnancy because of the trends in older age and higher obesity rates in pregnant women, “Integration of semiautonomous treatment algorithms similar to ours into routine obstetric practices could help reduce the health care burden and improve clinical outcomes, especially in areas with limited health care resources,” they concluded.
 

Algorithm may reduce disparities

The overall rise in maternal mortality in the United States remains a concern, but “Even more concerning are the disturbing racial disparities that persist across socioeconomic strata,” wrote Alisse Hauspurg, MD, of the University of Pittsburgh in an accompanying editorial. “There is clear evidence that expeditious treatment of obstetric hypertensive emergency reduces the risk of severe morbidities including stroke, eclampsia, and maternal death,” she emphasized, but compliance with the ACOG recommendations to treat severe hypertension within 30-60 minutes of confirmation remains low, she said.

In this study, not only did use of the algorithm reduce time to antihypertensive therapy, but more than 50% of patients were treated for severe hypertension within 15 minutes, and more than 90% within 60 minutes, “which was sustained after the implementation phase,” and aligns with the ACOG recommendations, Dr. Hauspurg said. “Although Martin et al.’s algorithm was limited to the initial management of obstetric hypertensive emergency, it could readily be expanded to follow the full ACOG algorithm for management of hypertension in pregnancy,” she noted.

In addition, Black women are more frequently diagnosed with hypertensive disorders of pregnancy, including severe hypertension, and the algorithm might improve disparities, she said.

“It is plausible that widespread implementation of such a semiautonomous algorithm at hospitals across the country could reduce delays in treatment and prevent hypertension-related morbidities,” said Dr. Hauspurg. “The use of innovative approaches to management of severe hypertension and other obstetric emergencies has the potential to allow provision of more equitable care by overcoming health care practitioner and system biases, which could meaningfully reduce disparities in care and change the trajectory of maternal morbidity and mortality in the United States,” she emphasized.
 

Need to create culture of safety

“Maternal mortality in the United States is the highest among developed nations, and shocking disparities exist in outcomes for non-Hispanic Black and American Indian/Alaskan Native women,” said Lisa Hollier, MD, of Texas Children’s Health Plan in Bellaire. “In a California review of maternal deaths, the greatest quality improvement opportunities were missed diagnosis and ineffective treatment of preeclampsia and related diseases, which occurred in 65% of the cases where women died of preeclampsia/eclampsia,” she said.

The current study “is very timely as more and more states across the nation are participating in the AIM (Alliance for Innovation on Maternal Health) programs to prevent pregnancy-related mortality,” Dr. Hollier noted.

“This study demonstrated a significant association between implementation of the algorithm and an increased percentage of treatment of severe hypertension within 30 minutes,” Dr. Hollier said. “With the implementation of a comprehensive program that included treatment algorithms, the Illinois Perinatal Quality Collaborative improved timely treatment for women with severe high blood pressure, increasing the percentage of patients treated within 60 minutes from 41% at baseline to 79% in the first year of the project.”

The take-home message is that “implementation of the semiautonomous treatment algorithm can address important clinical variation, including delays in appropriate treatment of severe hypertension,” said Dr. Hollier. However, “One of the potential barriers [to use of an algorithm] is the need for accurate, real-time clinical assessment. Resources must be available to ensure appropriate monitoring,” Dr. Hollier noted. “Collaboration and support of implementation of these treatment algorithms must extend through the nursing staff, the physicians, and advanced-practice providers. Medical staff and administrative leaders are essential in creating a culture of safety and continuous process improvement,” she said.

In addition, “long-term follow-up on the implementation of broader quality improvement programs is essential,” Dr. Hollier said. “While implementation of an algorithm can, and did, result in process improvements, assessment of broader implementation of evidence-based bundles, combined with a systematic approach to redesign of multiple related processes needs to occur and include outcomes of severe maternal morbidity and mortality,” she explained.

The study received no outside funding. The researchers had no financial conflicts to disclose.

Neither Dr. Hauspurg nor Dr. Hollier had financial conflicts to disclose.

Use of a semiautonomous algorithm to initiate treatment for hypertension emergencies in pregnancy significantly increased the number of individuals treated promptly, based on data from 959 obstetric patients.

Data show poor compliance with the current American College of Obstetricians and Gynecologists recommendations for treatment of acute severe hypertension with no more than 30-60 minutes’ delay; low compliance may be caused by “multiple factors including lack of intravenous access, inadequate health care practitioner or nursing availability, and implicit racial biases,” wrote Courtney Martin, DO, of Loma Linda (Calif.) University School of Medicine and colleagues.

Semiautomated treatment algorithms have been used to improve timely treatment of conditions including myocardial infarction, heart failure, acute stroke, and asthma, but their use in obstetrics to date has been limited, the researchers noted.

In a retrospective cohort study published in Obstetrics & Gynecology, the researchers identified pregnant and postpartum women treated for severe hypertension at a single center between January 2017 and March 2020. A semiautonomous treatment algorithm was implemented between May 2018 and March 2019. The algorithm included vital sign monitoring, blood pressure thresholds for diagnosis of severe hypertension, and automated order sets for recommended first-line antihypertensive therapy. The primary outcomes were treatment with antihypertensive therapy within 15, 30, and 60 minutes of diagnosis. “Severe hypertension was defined as systolic blood pressure 160 mm Hg or higher or diastolic blood pressure 110 mm Hg or higher,” the researchers said.

The study population was divided into three groups; a preimplementation group (373 patients) managed between January 2017 and April 2018, a during-implementation group (334 patients) managed between May 2018 and March 2019, and a postimplementation group (252 patients) managed between April 2019 and March 2020. Patient demographics were similar among all three groups.
 

Timely treatment improves with algorithm

Overall, treatment of severe hypertension within 15 minutes of diagnosis was 36.5% preimplementation, 45.8% during implementation, and 55.6% postimplementation. Severe hypertension treatment within 30 minutes of diagnosis was 65.9% preimplementation, 77.8% during implementation, and 79.0% post implementation. Differences were significant between pre- and post implementation for 15 minutes and 30 minutes, but no significant differences occurred in the patients treated within 60 minutes before and after implementation of the algorithm.

The study findings were limited by several factors, including the inability to separate peer-to-peer education and other training from the impact of the algorithm, as well as a lack of data on the effect of the algorithm on maternal or neonatal outcomes, the researchers noted.

However, the results support the potential of a semiautonomous algorithm to significantly improve adherence to the recommended treatment guidelines for severe hypertension in pregnancy and post partum, they said. Given the expected increase in hypertensive disorders in pregnancy because of the trends in older age and higher obesity rates in pregnant women, “Integration of semiautonomous treatment algorithms similar to ours into routine obstetric practices could help reduce the health care burden and improve clinical outcomes, especially in areas with limited health care resources,” they concluded.
 

Algorithm may reduce disparities

The overall rise in maternal mortality in the United States remains a concern, but “Even more concerning are the disturbing racial disparities that persist across socioeconomic strata,” wrote Alisse Hauspurg, MD, of the University of Pittsburgh in an accompanying editorial. “There is clear evidence that expeditious treatment of obstetric hypertensive emergency reduces the risk of severe morbidities including stroke, eclampsia, and maternal death,” she emphasized, but compliance with the ACOG recommendations to treat severe hypertension within 30-60 minutes of confirmation remains low, she said.

In this study, not only did use of the algorithm reduce time to antihypertensive therapy, but more than 50% of patients were treated for severe hypertension within 15 minutes, and more than 90% within 60 minutes, “which was sustained after the implementation phase,” and aligns with the ACOG recommendations, Dr. Hauspurg said. “Although Martin et al.’s algorithm was limited to the initial management of obstetric hypertensive emergency, it could readily be expanded to follow the full ACOG algorithm for management of hypertension in pregnancy,” she noted.

In addition, Black women are more frequently diagnosed with hypertensive disorders of pregnancy, including severe hypertension, and the algorithm might improve disparities, she said.

“It is plausible that widespread implementation of such a semiautonomous algorithm at hospitals across the country could reduce delays in treatment and prevent hypertension-related morbidities,” said Dr. Hauspurg. “The use of innovative approaches to management of severe hypertension and other obstetric emergencies has the potential to allow provision of more equitable care by overcoming health care practitioner and system biases, which could meaningfully reduce disparities in care and change the trajectory of maternal morbidity and mortality in the United States,” she emphasized.
 

Need to create culture of safety

“Maternal mortality in the United States is the highest among developed nations, and shocking disparities exist in outcomes for non-Hispanic Black and American Indian/Alaskan Native women,” said Lisa Hollier, MD, of Texas Children’s Health Plan in Bellaire. “In a California review of maternal deaths, the greatest quality improvement opportunities were missed diagnosis and ineffective treatment of preeclampsia and related diseases, which occurred in 65% of the cases where women died of preeclampsia/eclampsia,” she said.

The current study “is very timely as more and more states across the nation are participating in the AIM (Alliance for Innovation on Maternal Health) programs to prevent pregnancy-related mortality,” Dr. Hollier noted.

“This study demonstrated a significant association between implementation of the algorithm and an increased percentage of treatment of severe hypertension within 30 minutes,” Dr. Hollier said. “With the implementation of a comprehensive program that included treatment algorithms, the Illinois Perinatal Quality Collaborative improved timely treatment for women with severe high blood pressure, increasing the percentage of patients treated within 60 minutes from 41% at baseline to 79% in the first year of the project.”

The take-home message is that “implementation of the semiautonomous treatment algorithm can address important clinical variation, including delays in appropriate treatment of severe hypertension,” said Dr. Hollier. However, “One of the potential barriers [to use of an algorithm] is the need for accurate, real-time clinical assessment. Resources must be available to ensure appropriate monitoring,” Dr. Hollier noted. “Collaboration and support of implementation of these treatment algorithms must extend through the nursing staff, the physicians, and advanced-practice providers. Medical staff and administrative leaders are essential in creating a culture of safety and continuous process improvement,” she said.

In addition, “long-term follow-up on the implementation of broader quality improvement programs is essential,” Dr. Hollier said. “While implementation of an algorithm can, and did, result in process improvements, assessment of broader implementation of evidence-based bundles, combined with a systematic approach to redesign of multiple related processes needs to occur and include outcomes of severe maternal morbidity and mortality,” she explained.

The study received no outside funding. The researchers had no financial conflicts to disclose.

Neither Dr. Hauspurg nor Dr. Hollier had financial conflicts to disclose.

Use of a semiautonomous algorithm to initiate treatment for hypertension emergencies in pregnancy significantly increased the number of individuals treated promptly, based on data from 959 obstetric patients.

Data show poor compliance with the current American College of Obstetricians and Gynecologists recommendations for treatment of acute severe hypertension with no more than 30-60 minutes’ delay; low compliance may be caused by “multiple factors including lack of intravenous access, inadequate health care practitioner or nursing availability, and implicit racial biases,” wrote Courtney Martin, DO, of Loma Linda (Calif.) University School of Medicine and colleagues.

Semiautomated treatment algorithms have been used to improve timely treatment of conditions including myocardial infarction, heart failure, acute stroke, and asthma, but their use in obstetrics to date has been limited, the researchers noted.

In a retrospective cohort study published in Obstetrics & Gynecology, the researchers identified pregnant and postpartum women treated for severe hypertension at a single center between January 2017 and March 2020. A semiautonomous treatment algorithm was implemented between May 2018 and March 2019. The algorithm included vital sign monitoring, blood pressure thresholds for diagnosis of severe hypertension, and automated order sets for recommended first-line antihypertensive therapy. The primary outcomes were treatment with antihypertensive therapy within 15, 30, and 60 minutes of diagnosis. “Severe hypertension was defined as systolic blood pressure 160 mm Hg or higher or diastolic blood pressure 110 mm Hg or higher,” the researchers said.

The study population was divided into three groups; a preimplementation group (373 patients) managed between January 2017 and April 2018, a during-implementation group (334 patients) managed between May 2018 and March 2019, and a postimplementation group (252 patients) managed between April 2019 and March 2020. Patient demographics were similar among all three groups.
 

Timely treatment improves with algorithm

Overall, treatment of severe hypertension within 15 minutes of diagnosis was 36.5% preimplementation, 45.8% during implementation, and 55.6% postimplementation. Severe hypertension treatment within 30 minutes of diagnosis was 65.9% preimplementation, 77.8% during implementation, and 79.0% post implementation. Differences were significant between pre- and post implementation for 15 minutes and 30 minutes, but no significant differences occurred in the patients treated within 60 minutes before and after implementation of the algorithm.

The study findings were limited by several factors, including the inability to separate peer-to-peer education and other training from the impact of the algorithm, as well as a lack of data on the effect of the algorithm on maternal or neonatal outcomes, the researchers noted.

However, the results support the potential of a semiautonomous algorithm to significantly improve adherence to the recommended treatment guidelines for severe hypertension in pregnancy and post partum, they said. Given the expected increase in hypertensive disorders in pregnancy because of the trends in older age and higher obesity rates in pregnant women, “Integration of semiautonomous treatment algorithms similar to ours into routine obstetric practices could help reduce the health care burden and improve clinical outcomes, especially in areas with limited health care resources,” they concluded.
 

Algorithm may reduce disparities

The overall rise in maternal mortality in the United States remains a concern, but “Even more concerning are the disturbing racial disparities that persist across socioeconomic strata,” wrote Alisse Hauspurg, MD, of the University of Pittsburgh in an accompanying editorial. “There is clear evidence that expeditious treatment of obstetric hypertensive emergency reduces the risk of severe morbidities including stroke, eclampsia, and maternal death,” she emphasized, but compliance with the ACOG recommendations to treat severe hypertension within 30-60 minutes of confirmation remains low, she said.

In this study, not only did use of the algorithm reduce time to antihypertensive therapy, but more than 50% of patients were treated for severe hypertension within 15 minutes, and more than 90% within 60 minutes, “which was sustained after the implementation phase,” and aligns with the ACOG recommendations, Dr. Hauspurg said. “Although Martin et al.’s algorithm was limited to the initial management of obstetric hypertensive emergency, it could readily be expanded to follow the full ACOG algorithm for management of hypertension in pregnancy,” she noted.

In addition, Black women are more frequently diagnosed with hypertensive disorders of pregnancy, including severe hypertension, and the algorithm might improve disparities, she said.

“It is plausible that widespread implementation of such a semiautonomous algorithm at hospitals across the country could reduce delays in treatment and prevent hypertension-related morbidities,” said Dr. Hauspurg. “The use of innovative approaches to management of severe hypertension and other obstetric emergencies has the potential to allow provision of more equitable care by overcoming health care practitioner and system biases, which could meaningfully reduce disparities in care and change the trajectory of maternal morbidity and mortality in the United States,” she emphasized.
 

Need to create culture of safety

“Maternal mortality in the United States is the highest among developed nations, and shocking disparities exist in outcomes for non-Hispanic Black and American Indian/Alaskan Native women,” said Lisa Hollier, MD, of Texas Children’s Health Plan in Bellaire. “In a California review of maternal deaths, the greatest quality improvement opportunities were missed diagnosis and ineffective treatment of preeclampsia and related diseases, which occurred in 65% of the cases where women died of preeclampsia/eclampsia,” she said.

The current study “is very timely as more and more states across the nation are participating in the AIM (Alliance for Innovation on Maternal Health) programs to prevent pregnancy-related mortality,” Dr. Hollier noted.

“This study demonstrated a significant association between implementation of the algorithm and an increased percentage of treatment of severe hypertension within 30 minutes,” Dr. Hollier said. “With the implementation of a comprehensive program that included treatment algorithms, the Illinois Perinatal Quality Collaborative improved timely treatment for women with severe high blood pressure, increasing the percentage of patients treated within 60 minutes from 41% at baseline to 79% in the first year of the project.”

The take-home message is that “implementation of the semiautonomous treatment algorithm can address important clinical variation, including delays in appropriate treatment of severe hypertension,” said Dr. Hollier. However, “One of the potential barriers [to use of an algorithm] is the need for accurate, real-time clinical assessment. Resources must be available to ensure appropriate monitoring,” Dr. Hollier noted. “Collaboration and support of implementation of these treatment algorithms must extend through the nursing staff, the physicians, and advanced-practice providers. Medical staff and administrative leaders are essential in creating a culture of safety and continuous process improvement,” she said.

In addition, “long-term follow-up on the implementation of broader quality improvement programs is essential,” Dr. Hollier said. “While implementation of an algorithm can, and did, result in process improvements, assessment of broader implementation of evidence-based bundles, combined with a systematic approach to redesign of multiple related processes needs to occur and include outcomes of severe maternal morbidity and mortality,” she explained.

The study received no outside funding. The researchers had no financial conflicts to disclose.

Neither Dr. Hauspurg nor Dr. Hollier had financial conflicts to disclose.

This month’s editorial was jointly written by the editors of 10 prominent family medicine publications, including JFP, and is being published simultaneously in all 10 publications. In addition to this statement, each editor has developed action steps for their respective journals. At JFP, we plan to take the steps detailed here to help eliminate systemic racism. We will:

• continue to seek Black, Latino, and Native American physicians to serve on the JFP editorial advisory board.
• solicit manuscripts from these underrepresented groups of physicians.
• recruit peer reviewers from underrepresented communities.
• re-evaluate the thoroughness of manuscripts; where there are racial or ethnic differences in presentation of diseases or treatment outcomes, we will ensure that these differences are highlighted.

If you are interested in helping us to achieve these goals, I encourage you to contact me at [email protected].

We must all band together to eliminate disparities and biases in medical education and medical care so that all people receive the same high standard of respect and care that every human being deserves.

This month’s editorial was jointly written by the editors of 10 prominent family medicine publications, including JFP, and is being published simultaneously in all 10 publications. In addition to this statement, each editor has developed action steps for their respective journals. At JFP, we plan to take the steps detailed here to help eliminate systemic racism. We will:

• continue to seek Black, Latino, and Native American physicians to serve on the JFP editorial advisory board.
• solicit manuscripts from these underrepresented groups of physicians.
• recruit peer reviewers from underrepresented communities.
• re-evaluate the thoroughness of manuscripts; where there are racial or ethnic differences in presentation of diseases or treatment outcomes, we will ensure that these differences are highlighted.

If you are interested in helping us to achieve these goals, I encourage you to contact me at [email protected].

We must all band together to eliminate disparities and biases in medical education and medical care so that all people receive the same high standard of respect and care that every human being deserves.

This month’s editorial was jointly written by the editors of 10 prominent family medicine publications, including JFP, and is being published simultaneously in all 10 publications. In addition to this statement, each editor has developed action steps for their respective journals. At JFP, we plan to take the steps detailed here to help eliminate systemic racism. We will:

• continue to seek Black, Latino, and Native American physicians to serve on the JFP editorial advisory board.
• solicit manuscripts from these underrepresented groups of physicians.
• recruit peer reviewers from underrepresented communities.
• re-evaluate the thoroughness of manuscripts; where there are racial or ethnic differences in presentation of diseases or treatment outcomes, we will ensure that these differences are highlighted.

If you are interested in helping us to achieve these goals, I encourage you to contact me at [email protected].

We must all band together to eliminate disparities and biases in medical education and medical care so that all people receive the same high standard of respect and care that every human being deserves.

As the dermatology admissions cycle restarts, I reflect back on my journey as a Black woman applying to dermatology. Before deciding, I internally questioned, “Is dermatology right for me?” There were not many faces that looked like mine within the field. After committing to dermatology, I asked dermatologists—almost any who would spare a few minutes to talk to me—how to get into this specialty and be successful when applying. I spoke to advisors and friends at my home department, emailed dermatologists far and wide, approached conference lecturers after their presentations, sought out advice from current residents, and asked prior applicants what they thought was important to match into dermatology. There had been too many unmatched students before me who had achieved good grades and aced US Medical Licensing Examination Step 1. The equation for success was missing a variable.

Mentorship

One weekend, I attended a conference for patients with skin of color. I talked to a student who had taken a year off (retroactively after not matching in prior years). She told me that the biggest key to matching was mentorship; forming a strong relationship with a clinician or investigator who had seen how well you perform in clinic or during research was paramount. Having a collaborator or instructor write you a letter of recommendation and make calls on your behalf could be the difference between matching or taking another year off. More often than any other aspect of the application, it is a lack of mentorship that many students of color do not have access to when pursuing a highly competitive specialty such as dermatology.^1,2 In such a small field, applicants need someone to vouch for them—to speak on their behalf compassionately, invite them to collaborate on research projects, and inform them of conference opportunities to present their work.

Representation in Dermatology

We are told that you can accomplish anything with hard work and grit; however, without the platform to show how effectively you have worked, your efforts may never be seen. The diversity statistics for dermatology are clear and disheartening. Although 13% of Americans are Black, only 3% of all dermatologists are Black.^2,3 Just over 4% of dermatologists are Hispanic compared with 16% of the general population. The Association of American Medical Colleges reported that the overall 2015 medical school acceptance rate was 41%.⁴ White (44%), Asian (42%), and Hispanic or Latino (42%) applicants all had similar acceptance rates; however, only one-third of Black applicants were accepted. At graduation in 2015, White individuals were 51% of matriculants. Medical graduates were only 6% Black.⁴ What percentage of these 6% Black graduates thought about applying into dermatology? How many had someone to encourage them to pursue the specialty or a mentor who they could ask about the nuances and strategy to be a competitive applicant?

In addition to discrimination, social psychologists have described stereotype threat, a risk for minorities that occurs when negative stereotypes associated with an individual’s group status become relevant after perceived cues.⁵ Therefore, some students of color might avoid competitive specialties such as dermatology because of this internalized lack of confidence in their own abilities and performance thinking, “I’ll never be good enough to match into dermatology.” I have seen this discouraging perception when classmates doubt their own talent and achievements, which is a variation of imposter syndrome—when an individual doubts their abilities and may have an internal fear of eventually being exposed as a fraud.

After several publications received press coverage on the lack of diversity in dermatology applicant selection,^3,6,7 I looked around at my interview group composed of 25 to 40 interviewees and on average saw 2 to 3 Black applicants around the room. We always found a way during the packed interview day to find time to introduce ourselves. I almost always left with a new friend who shared feelings of anxiety, uncertainty, hope, and gratefulness from being the few Black people in the room. Bootstrapping might have helped us to make it into medical school, pass shelf examinations, and even get a great Step 1 score. However, the addition of mentorship—or better yet, sponsorship—helped to get us an interview in this competitive field. The impact of mentorship has been especially true for research, which has shown that students often gravitate toward mentors who look like them.⁸ However, the reality is that many Black and Hispanic students may be at a disadvantage for finding mentors in this way given that there are less than 10% of dermatologists who identify as individuals with skin of color. During the process of applying to dermatology, my greatest advocates were ethnically and racially diverse. The proverb is that it takes a village to raise a child; this reality extends to the medical student’s ability to thrive, not only in residency but also in the residency application process. My sponsors have been as different as their advice and perspectives, which helped me to think about the varied ways I viewed myself as an applicant and shaped what I looked for in residency.

Final Thoughts

Now that I have been a resident in the Department of Dermatology at the Warren Alpert Medical School of Brown University, I excitedly look for opportunities to mentor medical students and help create equity in the application process. Dermatology needs to increase the representation of minority applicants. Efforts to encourage minority medical students include joining the National Medical Association dermatology section through the Student National Medical Association, membership in the Skin of Color Society, getting involved with the Dermatology Interest Group at more medical schools, and awareness of medical student–friendly dermatology conferences. In addition, I was able to establish lifelong mentorship through the American Academy of Dermatology’s Minority Diversity Mentorship Program. One important component is an enhanced effort to increase the number of financial scholarships for away rotations (post–coronavirus disease 2019 pandemic) or application expenses geared to help underrepresented minorities. To truly increase diversity in dermatology, perhaps we need more physicians and residents willing to encourage students of color that dermatology is achievable.

As the dermatology admissions cycle restarts, I reflect back on my journey as a Black woman applying to dermatology. Before deciding, I internally questioned, “Is dermatology right for me?” There were not many faces that looked like mine within the field. After committing to dermatology, I asked dermatologists—almost any who would spare a few minutes to talk to me—how to get into this specialty and be successful when applying. I spoke to advisors and friends at my home department, emailed dermatologists far and wide, approached conference lecturers after their presentations, sought out advice from current residents, and asked prior applicants what they thought was important to match into dermatology. There had been too many unmatched students before me who had achieved good grades and aced US Medical Licensing Examination Step 1. The equation for success was missing a variable.

Mentorship

One weekend, I attended a conference for patients with skin of color. I talked to a student who had taken a year off (retroactively after not matching in prior years). She told me that the biggest key to matching was mentorship; forming a strong relationship with a clinician or investigator who had seen how well you perform in clinic or during research was paramount. Having a collaborator or instructor write you a letter of recommendation and make calls on your behalf could be the difference between matching or taking another year off. More often than any other aspect of the application, it is a lack of mentorship that many students of color do not have access to when pursuing a highly competitive specialty such as dermatology.^1,2 In such a small field, applicants need someone to vouch for them—to speak on their behalf compassionately, invite them to collaborate on research projects, and inform them of conference opportunities to present their work.

Representation in Dermatology

We are told that you can accomplish anything with hard work and grit; however, without the platform to show how effectively you have worked, your efforts may never be seen. The diversity statistics for dermatology are clear and disheartening. Although 13% of Americans are Black, only 3% of all dermatologists are Black.^2,3 Just over 4% of dermatologists are Hispanic compared with 16% of the general population. The Association of American Medical Colleges reported that the overall 2015 medical school acceptance rate was 41%.⁴ White (44%), Asian (42%), and Hispanic or Latino (42%) applicants all had similar acceptance rates; however, only one-third of Black applicants were accepted. At graduation in 2015, White individuals were 51% of matriculants. Medical graduates were only 6% Black.⁴ What percentage of these 6% Black graduates thought about applying into dermatology? How many had someone to encourage them to pursue the specialty or a mentor who they could ask about the nuances and strategy to be a competitive applicant?

In addition to discrimination, social psychologists have described stereotype threat, a risk for minorities that occurs when negative stereotypes associated with an individual’s group status become relevant after perceived cues.⁵ Therefore, some students of color might avoid competitive specialties such as dermatology because of this internalized lack of confidence in their own abilities and performance thinking, “I’ll never be good enough to match into dermatology.” I have seen this discouraging perception when classmates doubt their own talent and achievements, which is a variation of imposter syndrome—when an individual doubts their abilities and may have an internal fear of eventually being exposed as a fraud.

After several publications received press coverage on the lack of diversity in dermatology applicant selection,^3,6,7 I looked around at my interview group composed of 25 to 40 interviewees and on average saw 2 to 3 Black applicants around the room. We always found a way during the packed interview day to find time to introduce ourselves. I almost always left with a new friend who shared feelings of anxiety, uncertainty, hope, and gratefulness from being the few Black people in the room. Bootstrapping might have helped us to make it into medical school, pass shelf examinations, and even get a great Step 1 score. However, the addition of mentorship—or better yet, sponsorship—helped to get us an interview in this competitive field. The impact of mentorship has been especially true for research, which has shown that students often gravitate toward mentors who look like them.⁸ However, the reality is that many Black and Hispanic students may be at a disadvantage for finding mentors in this way given that there are less than 10% of dermatologists who identify as individuals with skin of color. During the process of applying to dermatology, my greatest advocates were ethnically and racially diverse. The proverb is that it takes a village to raise a child; this reality extends to the medical student’s ability to thrive, not only in residency but also in the residency application process. My sponsors have been as different as their advice and perspectives, which helped me to think about the varied ways I viewed myself as an applicant and shaped what I looked for in residency.

Final Thoughts

Now that I have been a resident in the Department of Dermatology at the Warren Alpert Medical School of Brown University, I excitedly look for opportunities to mentor medical students and help create equity in the application process. Dermatology needs to increase the representation of minority applicants. Efforts to encourage minority medical students include joining the National Medical Association dermatology section through the Student National Medical Association, membership in the Skin of Color Society, getting involved with the Dermatology Interest Group at more medical schools, and awareness of medical student–friendly dermatology conferences. In addition, I was able to establish lifelong mentorship through the American Academy of Dermatology’s Minority Diversity Mentorship Program. One important component is an enhanced effort to increase the number of financial scholarships for away rotations (post–coronavirus disease 2019 pandemic) or application expenses geared to help underrepresented minorities. To truly increase diversity in dermatology, perhaps we need more physicians and residents willing to encourage students of color that dermatology is achievable.

As the dermatology admissions cycle restarts, I reflect back on my journey as a Black woman applying to dermatology. Before deciding, I internally questioned, “Is dermatology right for me?” There were not many faces that looked like mine within the field. After committing to dermatology, I asked dermatologists—almost any who would spare a few minutes to talk to me—how to get into this specialty and be successful when applying. I spoke to advisors and friends at my home department, emailed dermatologists far and wide, approached conference lecturers after their presentations, sought out advice from current residents, and asked prior applicants what they thought was important to match into dermatology. There had been too many unmatched students before me who had achieved good grades and aced US Medical Licensing Examination Step 1. The equation for success was missing a variable.

Mentorship

One weekend, I attended a conference for patients with skin of color. I talked to a student who had taken a year off (retroactively after not matching in prior years). She told me that the biggest key to matching was mentorship; forming a strong relationship with a clinician or investigator who had seen how well you perform in clinic or during research was paramount. Having a collaborator or instructor write you a letter of recommendation and make calls on your behalf could be the difference between matching or taking another year off. More often than any other aspect of the application, it is a lack of mentorship that many students of color do not have access to when pursuing a highly competitive specialty such as dermatology.^1,2 In such a small field, applicants need someone to vouch for them—to speak on their behalf compassionately, invite them to collaborate on research projects, and inform them of conference opportunities to present their work.

Representation in Dermatology

We are told that you can accomplish anything with hard work and grit; however, without the platform to show how effectively you have worked, your efforts may never be seen. The diversity statistics for dermatology are clear and disheartening. Although 13% of Americans are Black, only 3% of all dermatologists are Black.^2,3 Just over 4% of dermatologists are Hispanic compared with 16% of the general population. The Association of American Medical Colleges reported that the overall 2015 medical school acceptance rate was 41%.⁴ White (44%), Asian (42%), and Hispanic or Latino (42%) applicants all had similar acceptance rates; however, only one-third of Black applicants were accepted. At graduation in 2015, White individuals were 51% of matriculants. Medical graduates were only 6% Black.⁴ What percentage of these 6% Black graduates thought about applying into dermatology? How many had someone to encourage them to pursue the specialty or a mentor who they could ask about the nuances and strategy to be a competitive applicant?

In addition to discrimination, social psychologists have described stereotype threat, a risk for minorities that occurs when negative stereotypes associated with an individual’s group status become relevant after perceived cues.⁵ Therefore, some students of color might avoid competitive specialties such as dermatology because of this internalized lack of confidence in their own abilities and performance thinking, “I’ll never be good enough to match into dermatology.” I have seen this discouraging perception when classmates doubt their own talent and achievements, which is a variation of imposter syndrome—when an individual doubts their abilities and may have an internal fear of eventually being exposed as a fraud.

After several publications received press coverage on the lack of diversity in dermatology applicant selection,^3,6,7 I looked around at my interview group composed of 25 to 40 interviewees and on average saw 2 to 3 Black applicants around the room. We always found a way during the packed interview day to find time to introduce ourselves. I almost always left with a new friend who shared feelings of anxiety, uncertainty, hope, and gratefulness from being the few Black people in the room. Bootstrapping might have helped us to make it into medical school, pass shelf examinations, and even get a great Step 1 score. However, the addition of mentorship—or better yet, sponsorship—helped to get us an interview in this competitive field. The impact of mentorship has been especially true for research, which has shown that students often gravitate toward mentors who look like them.⁸ However, the reality is that many Black and Hispanic students may be at a disadvantage for finding mentors in this way given that there are less than 10% of dermatologists who identify as individuals with skin of color. During the process of applying to dermatology, my greatest advocates were ethnically and racially diverse. The proverb is that it takes a village to raise a child; this reality extends to the medical student’s ability to thrive, not only in residency but also in the residency application process. My sponsors have been as different as their advice and perspectives, which helped me to think about the varied ways I viewed myself as an applicant and shaped what I looked for in residency.

Final Thoughts

Now that I have been a resident in the Department of Dermatology at the Warren Alpert Medical School of Brown University, I excitedly look for opportunities to mentor medical students and help create equity in the application process. Dermatology needs to increase the representation of minority applicants. Efforts to encourage minority medical students include joining the National Medical Association dermatology section through the Student National Medical Association, membership in the Skin of Color Society, getting involved with the Dermatology Interest Group at more medical schools, and awareness of medical student–friendly dermatology conferences. In addition, I was able to establish lifelong mentorship through the American Academy of Dermatology’s Minority Diversity Mentorship Program. One important component is an enhanced effort to increase the number of financial scholarships for away rotations (post–coronavirus disease 2019 pandemic) or application expenses geared to help underrepresented minorities. To truly increase diversity in dermatology, perhaps we need more physicians and residents willing to encourage students of color that dermatology is achievable.

Although inflammatory bowel disease (IBD) affects primarily White patients, about one-quarter of cases are found in non-White racial and ethnic groups. Various factors have combined to lead to disparities in treatment and outcomes for non-Whites with IBD.

Ethnic and racial disparities, along with socioeconomic factors, were the subject of a presentation by Ruby Greywoode, MD, at the annual congress of the Crohn’s & Colitis Foundation and the American Gastroenterological Association.

“Historical and present-day realities of racial inequity and factors that contribute to socioeconomic status [include] educational and housing policies, employment practices, and generational wealth. Addressing health disparities requires acknowledging these systemic factors,” said Dr. Greywoode, who is with Montefiore Medical Center in New York.

An important concept in discussing health disparity is social determinants of health, which refers to nonbiological factors that affect health and health outcomes. These are “the conditions in which people live, work, learn, and play that affect their health and their quality of life,” said Dr. Greywoode. 

Dr. Greywoode shared examples of social determinants that affect economic stability and financial worry. One study found that one in six IBD patients reported not taking their medications because of cost considerations. A survey of about 900 adults showed that 1 in 4 delayed medical care – half of those because of cost; patients who delayed care were 2.5 times more likely to report an IBD flare in the previous year.

Another important issue is food insecurity. Other presenters at the session emphasized the importance of high-quality nutrition in IBD, and Dr. Greywoode presented one survey showing that only 9% of patients who had both food security and social support reported cost-related medication nonadherence. Among those that had either food insecurity or poor social support, 12% reported cost-related medication nonadherence, but the proportion jumped to 57% among patients who had both food insecurity and lack of social support.

Session comoderator Kelly Issokson noted that socioeconomic factors often interfere with adoption of healthy diets. Whole foods and plant-based foods are expensive, and the financial pressures of the COVID-19 epidemic have made that worse. “Millions of people are slipping into poverty and food insecurity. This is one of the things she highlighted as factors in medication nonadherence,” said Ms. Issokson, who is the clinical nutritional coordinator at the digestive disease clinic at Cedars-Sinai Medical Center in Los Angeles.

Dr. Greywoode also described studies that looked at race, socioeconomic status, and IBD outcomes. A review from 2013 showed disparities among Whites, African Americans, and Hispanics with respect to undergoing ulcerative colitis–related colectomy and Crohn’s disease–related bowel resection. Ulcerative colitis patients on Medicaid had 230% greater in-patient mortality, compared with patients with private insurance, even after adjustment for multiple confounders.

But inequities are not static. “Since this publication, we have numerous other studies drawing conclusions that sometimes agree with and sometimes conflict with it. My belief is that health disparities in IBD will continue to be an active area of research. We know that it takes vigilance to identify, track, and address any disparities when they do arise,” said Dr. Greywoode.

Dr. Greywoode also noted that phenotypic differences based on race and ethnicity influence disparities. She showed results from a meta-analysis that found a difference in the frequency of perianal Crohn’s disease by race and ethnicity; the highest frequency occurred in Black patients (31%), followed by Asians (22%), Whites (14%), and Hispanics (13%). Another study showed that African American patients with Crohn’s disease were more likely to develop a new abscess (adjusted odds ratio, 2.27; 95% confidence interval, 1.31-3.93) or anal fissure (aOR, 1.76; 95% CI, 1.01-3.07), and were also more likely to be initiated on an anti–tumor necrosis factor drug (aOR, 1.85; 95% CI, 1.09-3.14).

Those differences underscore the need to recognize that IBD is not just a disease for White patients. “As we move forward in IBD research, we recognize that individuals of European ancestry are not the only ones who have IBD. There is a growing diverse racial and ethnic population with IBD,” said Dr. Greywoode.

She noted that, in the United States, it is estimated that about one in four adult patients are non-Hispanic African American, Hispanic, Asians, or other ethnicities. Nevertheless, Whites are overrepresented among participants in IBD clinical trials. Some trials are composed of as much as 95% White patients, and sometimes race isn’t even listed. “It’s unclear if [race/ethnicity data are] not collected or not deemed important, but we know that what is not collected is not measured, and what is not measured can’t be evaluated, either to praise or constructively criticize,” said Dr. Greywoode.

Fortunately, there are efforts in place to improve representation in clinical trials. There has been a mandate for almost 3 decades that federally funded research must include racial and ethnic minorities who have been traditionally underrepresented. The Food and Drug Administration has also provided guidance to industry to improve diversity in clinical trial participation, and industry groups have developed strategies, including improved representation among investigators and related early-career development programs. At the community and independent health care practice levels, clinical trial networks encourage patient participation with regulatory and data management support to bolster practices with insufficient resources.

Underrepresentation in clinical trials resonated with comoderator Tina Aswani Omprakash, who is a patient advocate and a master’s in public health student at the Icahn School of Medicine at Mount Sinai, New York. She called for greater awareness among physicians that IBD can occur among people of all backgrounds. “[Providers] would look at me and [say]: ‘There’s no way that, as a South Asian woman, you have that kind of disease.’ There’s that lack of believability,” said Ms. Aswani Omprakash.

Greater recognition of the diversity of patients, as well as the phenotypic differences found among ethnicities, could also inform clinical trial participation and, ultimately, more personalized medicine. “We have to look at these things, observe how they’re affecting populations differently, so that we can have proper medication solutions,” said Ms. Aswani Omprakash.

Dr. Greywoode and Ms. Issokson have no relevant financial disclosures. Ms. Aswani Omprakash has consulted for Genentech, AbbVie, Janssen, and Arena.

The AGA applauds researchers who are working to raise our awareness of health disparities in digestive diseases. The AGA is committed to addressing this important societal issue head on. Learn more about AGA’s commitment through the AGA Equity Project.

Updated Feb. 17, 2021.
 

Although inflammatory bowel disease (IBD) affects primarily White patients, about one-quarter of cases are found in non-White racial and ethnic groups. Various factors have combined to lead to disparities in treatment and outcomes for non-Whites with IBD.

Ethnic and racial disparities, along with socioeconomic factors, were the subject of a presentation by Ruby Greywoode, MD, at the annual congress of the Crohn’s & Colitis Foundation and the American Gastroenterological Association.

“Historical and present-day realities of racial inequity and factors that contribute to socioeconomic status [include] educational and housing policies, employment practices, and generational wealth. Addressing health disparities requires acknowledging these systemic factors,” said Dr. Greywoode, who is with Montefiore Medical Center in New York.

An important concept in discussing health disparity is social determinants of health, which refers to nonbiological factors that affect health and health outcomes. These are “the conditions in which people live, work, learn, and play that affect their health and their quality of life,” said Dr. Greywoode. 

Dr. Greywoode shared examples of social determinants that affect economic stability and financial worry. One study found that one in six IBD patients reported not taking their medications because of cost considerations. A survey of about 900 adults showed that 1 in 4 delayed medical care – half of those because of cost; patients who delayed care were 2.5 times more likely to report an IBD flare in the previous year.

Another important issue is food insecurity. Other presenters at the session emphasized the importance of high-quality nutrition in IBD, and Dr. Greywoode presented one survey showing that only 9% of patients who had both food security and social support reported cost-related medication nonadherence. Among those that had either food insecurity or poor social support, 12% reported cost-related medication nonadherence, but the proportion jumped to 57% among patients who had both food insecurity and lack of social support.

Session comoderator Kelly Issokson noted that socioeconomic factors often interfere with adoption of healthy diets. Whole foods and plant-based foods are expensive, and the financial pressures of the COVID-19 epidemic have made that worse. “Millions of people are slipping into poverty and food insecurity. This is one of the things she highlighted as factors in medication nonadherence,” said Ms. Issokson, who is the clinical nutritional coordinator at the digestive disease clinic at Cedars-Sinai Medical Center in Los Angeles.

Dr. Greywoode also described studies that looked at race, socioeconomic status, and IBD outcomes. A review from 2013 showed disparities among Whites, African Americans, and Hispanics with respect to undergoing ulcerative colitis–related colectomy and Crohn’s disease–related bowel resection. Ulcerative colitis patients on Medicaid had 230% greater in-patient mortality, compared with patients with private insurance, even after adjustment for multiple confounders.

But inequities are not static. “Since this publication, we have numerous other studies drawing conclusions that sometimes agree with and sometimes conflict with it. My belief is that health disparities in IBD will continue to be an active area of research. We know that it takes vigilance to identify, track, and address any disparities when they do arise,” said Dr. Greywoode.

Dr. Greywoode also noted that phenotypic differences based on race and ethnicity influence disparities. She showed results from a meta-analysis that found a difference in the frequency of perianal Crohn’s disease by race and ethnicity; the highest frequency occurred in Black patients (31%), followed by Asians (22%), Whites (14%), and Hispanics (13%). Another study showed that African American patients with Crohn’s disease were more likely to develop a new abscess (adjusted odds ratio, 2.27; 95% confidence interval, 1.31-3.93) or anal fissure (aOR, 1.76; 95% CI, 1.01-3.07), and were also more likely to be initiated on an anti–tumor necrosis factor drug (aOR, 1.85; 95% CI, 1.09-3.14).

Those differences underscore the need to recognize that IBD is not just a disease for White patients. “As we move forward in IBD research, we recognize that individuals of European ancestry are not the only ones who have IBD. There is a growing diverse racial and ethnic population with IBD,” said Dr. Greywoode.

She noted that, in the United States, it is estimated that about one in four adult patients are non-Hispanic African American, Hispanic, Asians, or other ethnicities. Nevertheless, Whites are overrepresented among participants in IBD clinical trials. Some trials are composed of as much as 95% White patients, and sometimes race isn’t even listed. “It’s unclear if [race/ethnicity data are] not collected or not deemed important, but we know that what is not collected is not measured, and what is not measured can’t be evaluated, either to praise or constructively criticize,” said Dr. Greywoode.

Fortunately, there are efforts in place to improve representation in clinical trials. There has been a mandate for almost 3 decades that federally funded research must include racial and ethnic minorities who have been traditionally underrepresented. The Food and Drug Administration has also provided guidance to industry to improve diversity in clinical trial participation, and industry groups have developed strategies, including improved representation among investigators and related early-career development programs. At the community and independent health care practice levels, clinical trial networks encourage patient participation with regulatory and data management support to bolster practices with insufficient resources.

Underrepresentation in clinical trials resonated with comoderator Tina Aswani Omprakash, who is a patient advocate and a master’s in public health student at the Icahn School of Medicine at Mount Sinai, New York. She called for greater awareness among physicians that IBD can occur among people of all backgrounds. “[Providers] would look at me and [say]: ‘There’s no way that, as a South Asian woman, you have that kind of disease.’ There’s that lack of believability,” said Ms. Aswani Omprakash.

Greater recognition of the diversity of patients, as well as the phenotypic differences found among ethnicities, could also inform clinical trial participation and, ultimately, more personalized medicine. “We have to look at these things, observe how they’re affecting populations differently, so that we can have proper medication solutions,” said Ms. Aswani Omprakash.

Dr. Greywoode and Ms. Issokson have no relevant financial disclosures. Ms. Aswani Omprakash has consulted for Genentech, AbbVie, Janssen, and Arena.

The AGA applauds researchers who are working to raise our awareness of health disparities in digestive diseases. The AGA is committed to addressing this important societal issue head on. Learn more about AGA’s commitment through the AGA Equity Project.

Updated Feb. 17, 2021.
 

Although inflammatory bowel disease (IBD) affects primarily White patients, about one-quarter of cases are found in non-White racial and ethnic groups. Various factors have combined to lead to disparities in treatment and outcomes for non-Whites with IBD.

Ethnic and racial disparities, along with socioeconomic factors, were the subject of a presentation by Ruby Greywoode, MD, at the annual congress of the Crohn’s & Colitis Foundation and the American Gastroenterological Association.

“Historical and present-day realities of racial inequity and factors that contribute to socioeconomic status [include] educational and housing policies, employment practices, and generational wealth. Addressing health disparities requires acknowledging these systemic factors,” said Dr. Greywoode, who is with Montefiore Medical Center in New York.

An important concept in discussing health disparity is social determinants of health, which refers to nonbiological factors that affect health and health outcomes. These are “the conditions in which people live, work, learn, and play that affect their health and their quality of life,” said Dr. Greywoode. 

Dr. Greywoode shared examples of social determinants that affect economic stability and financial worry. One study found that one in six IBD patients reported not taking their medications because of cost considerations. A survey of about 900 adults showed that 1 in 4 delayed medical care – half of those because of cost; patients who delayed care were 2.5 times more likely to report an IBD flare in the previous year.

Another important issue is food insecurity. Other presenters at the session emphasized the importance of high-quality nutrition in IBD, and Dr. Greywoode presented one survey showing that only 9% of patients who had both food security and social support reported cost-related medication nonadherence. Among those that had either food insecurity or poor social support, 12% reported cost-related medication nonadherence, but the proportion jumped to 57% among patients who had both food insecurity and lack of social support.

Session comoderator Kelly Issokson noted that socioeconomic factors often interfere with adoption of healthy diets. Whole foods and plant-based foods are expensive, and the financial pressures of the COVID-19 epidemic have made that worse. “Millions of people are slipping into poverty and food insecurity. This is one of the things she highlighted as factors in medication nonadherence,” said Ms. Issokson, who is the clinical nutritional coordinator at the digestive disease clinic at Cedars-Sinai Medical Center in Los Angeles.

Dr. Greywoode also described studies that looked at race, socioeconomic status, and IBD outcomes. A review from 2013 showed disparities among Whites, African Americans, and Hispanics with respect to undergoing ulcerative colitis–related colectomy and Crohn’s disease–related bowel resection. Ulcerative colitis patients on Medicaid had 230% greater in-patient mortality, compared with patients with private insurance, even after adjustment for multiple confounders.

But inequities are not static. “Since this publication, we have numerous other studies drawing conclusions that sometimes agree with and sometimes conflict with it. My belief is that health disparities in IBD will continue to be an active area of research. We know that it takes vigilance to identify, track, and address any disparities when they do arise,” said Dr. Greywoode.

Dr. Greywoode also noted that phenotypic differences based on race and ethnicity influence disparities. She showed results from a meta-analysis that found a difference in the frequency of perianal Crohn’s disease by race and ethnicity; the highest frequency occurred in Black patients (31%), followed by Asians (22%), Whites (14%), and Hispanics (13%). Another study showed that African American patients with Crohn’s disease were more likely to develop a new abscess (adjusted odds ratio, 2.27; 95% confidence interval, 1.31-3.93) or anal fissure (aOR, 1.76; 95% CI, 1.01-3.07), and were also more likely to be initiated on an anti–tumor necrosis factor drug (aOR, 1.85; 95% CI, 1.09-3.14).

Those differences underscore the need to recognize that IBD is not just a disease for White patients. “As we move forward in IBD research, we recognize that individuals of European ancestry are not the only ones who have IBD. There is a growing diverse racial and ethnic population with IBD,” said Dr. Greywoode.

She noted that, in the United States, it is estimated that about one in four adult patients are non-Hispanic African American, Hispanic, Asians, or other ethnicities. Nevertheless, Whites are overrepresented among participants in IBD clinical trials. Some trials are composed of as much as 95% White patients, and sometimes race isn’t even listed. “It’s unclear if [race/ethnicity data are] not collected or not deemed important, but we know that what is not collected is not measured, and what is not measured can’t be evaluated, either to praise or constructively criticize,” said Dr. Greywoode.

Fortunately, there are efforts in place to improve representation in clinical trials. There has been a mandate for almost 3 decades that federally funded research must include racial and ethnic minorities who have been traditionally underrepresented. The Food and Drug Administration has also provided guidance to industry to improve diversity in clinical trial participation, and industry groups have developed strategies, including improved representation among investigators and related early-career development programs. At the community and independent health care practice levels, clinical trial networks encourage patient participation with regulatory and data management support to bolster practices with insufficient resources.

Underrepresentation in clinical trials resonated with comoderator Tina Aswani Omprakash, who is a patient advocate and a master’s in public health student at the Icahn School of Medicine at Mount Sinai, New York. She called for greater awareness among physicians that IBD can occur among people of all backgrounds. “[Providers] would look at me and [say]: ‘There’s no way that, as a South Asian woman, you have that kind of disease.’ There’s that lack of believability,” said Ms. Aswani Omprakash.

Greater recognition of the diversity of patients, as well as the phenotypic differences found among ethnicities, could also inform clinical trial participation and, ultimately, more personalized medicine. “We have to look at these things, observe how they’re affecting populations differently, so that we can have proper medication solutions,” said Ms. Aswani Omprakash.

Dr. Greywoode and Ms. Issokson have no relevant financial disclosures. Ms. Aswani Omprakash has consulted for Genentech, AbbVie, Janssen, and Arena.

The AGA applauds researchers who are working to raise our awareness of health disparities in digestive diseases. The AGA is committed to addressing this important societal issue head on. Learn more about AGA’s commitment through the AGA Equity Project.

Updated Feb. 17, 2021.
 

The American Psychiatric Association has issued a formal apology for its past support of structural racism in psychiatry.

The apology, issued Jan. 18, coincided with the federal holiday honoring the life and work of civil rights activist Dr. Martin Luther King Jr.

“We apologize for our role in perpetrating structural racism in this country, and we hope to begin to make amends for APA’s and psychiatry’s history of actions, intentional and not, that hurt Black, indigenous, and people of color,” APA President Jeffrey Geller, MD, MPH, said in a statement.

The apology was written and issued by the APA Board of Trustees. It acknowledges practices and events in psychiatry that contributed to racial inequality, and expresses the organization’s commitment to developing antiracist policies that promote equity in mental health for all.

“This apology is one important step we needed to take to move forward to a more equitable future. The board is issuing this document on Martin Luther King Jr. Day, because we hope that it honors his life’s work of reconciliation and equality. We do not take that legacy or his call to action lightly and will continue our important work,” said Dr. Geller.

The apology is posted on the APA website along with a related document highlighting some historical instances of racism in organized psychiatry.

One involved the Eastern State Hospital in Williamsburg, Va., the nation’s first psychiatric care facility, founded in 1773.

Eastern State, which for a time in the 1800s was called the Eastern Lunatic Asylum, was not segregated when founded. However, 70 years later, when the 13 founders of what is now the APA met to discuss improvements in mental health care delivery, the treatment system they created and the organization they founded aligned with that era’s racist social and political policies. In this system, Black patients received psychiatric care separately from White patients, the APA said.

The APA also acknowledged failing to act in Black Americans’ best interest at critical points in the United States’ sociopolitical evolution throughout the 19th and 20th centuries.

“This inactivity was notably evident while white supremacists lynched Black people during the Reconstruction Era as well as when Jim Crow segregation was in effect, which led to ‘separate but equal’ standards of care starting in 1896,” the APA said.

Later, the APA failed to declare support for Brown v. Board of Education of Topeka in 1954, along with further major civil rights legislation designed to improve social and psychological conditions for Black people, the organization admitted.

Throughout the decades that followed, psychiatric misdiagnosis among Black, indigenous, and people of color populations were also common, the APA acknowledged.

For example, late 20th century psychiatrists commonly attributed their minority patients’ frustrations to schizophrenia, while categorizing similar behaviors as “neuroticism” in White patients.

The APA pointed to one study which found that APA members diagnosed more Black than White patients with schizophrenia, even when both had otherwise identical clinical presentations.

“This reveals the basis for embedded discrimination within psychiatry that has contributed to reduced quality of care” for Black, indigenous, and people of color, and “perpetuation of dangerous stereotypes,” the APA said.

Saul Levin, MD, the APA’s medical director and CEO, said the Board of Trustees has taken “an important step in issuing this apology. The APA administration is committed to working toward inclusion, health equity, and fairness that everyone deserves.”

The APA Board of Trustees began drafting the apology late last year after it concluded that events and persistent inequities in health care and psychiatry had highlighted an organizational need for action.

The APA’s Presidential Task Force on Structural Racism is continuing with efforts to educate and engage members on the issue and implement changes within the organization.

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

The American Psychiatric Association has issued a formal apology for its past support of structural racism in psychiatry.

The apology, issued Jan. 18, coincided with the federal holiday honoring the life and work of civil rights activist Dr. Martin Luther King Jr.

“We apologize for our role in perpetrating structural racism in this country, and we hope to begin to make amends for APA’s and psychiatry’s history of actions, intentional and not, that hurt Black, indigenous, and people of color,” APA President Jeffrey Geller, MD, MPH, said in a statement.

The apology was written and issued by the APA Board of Trustees. It acknowledges practices and events in psychiatry that contributed to racial inequality, and expresses the organization’s commitment to developing antiracist policies that promote equity in mental health for all.

“This apology is one important step we needed to take to move forward to a more equitable future. The board is issuing this document on Martin Luther King Jr. Day, because we hope that it honors his life’s work of reconciliation and equality. We do not take that legacy or his call to action lightly and will continue our important work,” said Dr. Geller.

The apology is posted on the APA website along with a related document highlighting some historical instances of racism in organized psychiatry.

One involved the Eastern State Hospital in Williamsburg, Va., the nation’s first psychiatric care facility, founded in 1773.

Eastern State, which for a time in the 1800s was called the Eastern Lunatic Asylum, was not segregated when founded. However, 70 years later, when the 13 founders of what is now the APA met to discuss improvements in mental health care delivery, the treatment system they created and the organization they founded aligned with that era’s racist social and political policies. In this system, Black patients received psychiatric care separately from White patients, the APA said.

The APA also acknowledged failing to act in Black Americans’ best interest at critical points in the United States’ sociopolitical evolution throughout the 19th and 20th centuries.

“This inactivity was notably evident while white supremacists lynched Black people during the Reconstruction Era as well as when Jim Crow segregation was in effect, which led to ‘separate but equal’ standards of care starting in 1896,” the APA said.

Later, the APA failed to declare support for Brown v. Board of Education of Topeka in 1954, along with further major civil rights legislation designed to improve social and psychological conditions for Black people, the organization admitted.

Throughout the decades that followed, psychiatric misdiagnosis among Black, indigenous, and people of color populations were also common, the APA acknowledged.

For example, late 20th century psychiatrists commonly attributed their minority patients’ frustrations to schizophrenia, while categorizing similar behaviors as “neuroticism” in White patients.

The APA pointed to one study which found that APA members diagnosed more Black than White patients with schizophrenia, even when both had otherwise identical clinical presentations.

“This reveals the basis for embedded discrimination within psychiatry that has contributed to reduced quality of care” for Black, indigenous, and people of color, and “perpetuation of dangerous stereotypes,” the APA said.

Saul Levin, MD, the APA’s medical director and CEO, said the Board of Trustees has taken “an important step in issuing this apology. The APA administration is committed to working toward inclusion, health equity, and fairness that everyone deserves.”

The APA Board of Trustees began drafting the apology late last year after it concluded that events and persistent inequities in health care and psychiatry had highlighted an organizational need for action.

The APA’s Presidential Task Force on Structural Racism is continuing with efforts to educate and engage members on the issue and implement changes within the organization.

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

The American Psychiatric Association has issued a formal apology for its past support of structural racism in psychiatry.

The apology, issued Jan. 18, coincided with the federal holiday honoring the life and work of civil rights activist Dr. Martin Luther King Jr.

“We apologize for our role in perpetrating structural racism in this country, and we hope to begin to make amends for APA’s and psychiatry’s history of actions, intentional and not, that hurt Black, indigenous, and people of color,” APA President Jeffrey Geller, MD, MPH, said in a statement.

The apology was written and issued by the APA Board of Trustees. It acknowledges practices and events in psychiatry that contributed to racial inequality, and expresses the organization’s commitment to developing antiracist policies that promote equity in mental health for all.

“This apology is one important step we needed to take to move forward to a more equitable future. The board is issuing this document on Martin Luther King Jr. Day, because we hope that it honors his life’s work of reconciliation and equality. We do not take that legacy or his call to action lightly and will continue our important work,” said Dr. Geller.

The apology is posted on the APA website along with a related document highlighting some historical instances of racism in organized psychiatry.

One involved the Eastern State Hospital in Williamsburg, Va., the nation’s first psychiatric care facility, founded in 1773.

Eastern State, which for a time in the 1800s was called the Eastern Lunatic Asylum, was not segregated when founded. However, 70 years later, when the 13 founders of what is now the APA met to discuss improvements in mental health care delivery, the treatment system they created and the organization they founded aligned with that era’s racist social and political policies. In this system, Black patients received psychiatric care separately from White patients, the APA said.

The APA also acknowledged failing to act in Black Americans’ best interest at critical points in the United States’ sociopolitical evolution throughout the 19th and 20th centuries.

“This inactivity was notably evident while white supremacists lynched Black people during the Reconstruction Era as well as when Jim Crow segregation was in effect, which led to ‘separate but equal’ standards of care starting in 1896,” the APA said.

Later, the APA failed to declare support for Brown v. Board of Education of Topeka in 1954, along with further major civil rights legislation designed to improve social and psychological conditions for Black people, the organization admitted.

Throughout the decades that followed, psychiatric misdiagnosis among Black, indigenous, and people of color populations were also common, the APA acknowledged.

For example, late 20th century psychiatrists commonly attributed their minority patients’ frustrations to schizophrenia, while categorizing similar behaviors as “neuroticism” in White patients.

The APA pointed to one study which found that APA members diagnosed more Black than White patients with schizophrenia, even when both had otherwise identical clinical presentations.

“This reveals the basis for embedded discrimination within psychiatry that has contributed to reduced quality of care” for Black, indigenous, and people of color, and “perpetuation of dangerous stereotypes,” the APA said.

Saul Levin, MD, the APA’s medical director and CEO, said the Board of Trustees has taken “an important step in issuing this apology. The APA administration is committed to working toward inclusion, health equity, and fairness that everyone deserves.”

The APA Board of Trustees began drafting the apology late last year after it concluded that events and persistent inequities in health care and psychiatry had highlighted an organizational need for action.

The APA’s Presidential Task Force on Structural Racism is continuing with efforts to educate and engage members on the issue and implement changes within the organization.

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

Stephanie Florez-Pollack, MD, a dermatology resident at the University of Pennsylvania, Philadelphia, began considering the field of dermatology when, as part of the Latino Medical Students Association, she was invited by Amit Pandya, MD, to a pizza party and dermatology discussion during her first year of medical school at the University of Texas Southwestern Medical Center, Dallas.

Courtesy Dr. Stephanie Flores-Pollack

There, she met three Latinx residents who were part of the University of Texas Southwestern dermatology program. “I was so excited to hear their stories, where they came from, and how they ended up in dermatology,” she said. Dermatology had not been on her radar screen. Now there was a spark.

Volunteering at the free Agape dermatology clinic in Dallas later that year sharpened her interest. “For the first time, I really saw myself working in the field. Hearing patients’ stories and what they went through with what many people might think are very simple skin diseases made me realize there was potential to make a big impact in a person’s life,” said Dr. Florez-Pollack, who immigrated from Colombia with her family when she was 15.

Dr. Florez-Pollack’s journey into dermatology as an underrepresented-in-medicine (UIM) physician-in-training offers a window into a movement underway that aims to create a diverse dermatology workforce – one that reflects the ethnic and racial make-up of the population. It’s a movement that involves early outreach to medical students, stepped-up mentorship and sponsorship, implicit bias training, and holistic review of residency applicants.

There is no published study of all the changes being made – of how many dermatology programs have new outreach programs, for instance, or new approaches to resident application reviews. However, participation in the American Academy of Dermatology Diversity Champions program increased significantly between 2019 and 2020, and a sizable body of articles and editorials on diversity have been published in the dermatology literature in recent years, including at least several on holistic review of resident applications. Five years ago, there were few publications, sources said.

“The conversation is happening now at multiple levels, including in our peer-reviewed literature, where people are looking objectively at ... how we can make changes for the better,” said Nada Elbuluk, MD, director of the dermatology diversity and inclusion program at the University of Southern California, Los Angeles.

Unpublished findings also indicate that the number of UIM dermatology residents is inching upward. “Residency selection may not be on everyone’s mind, but an understanding of how we select people into our specialty is something every derm should know about and care about,” said Kanade Shinkai, MD, PhD, professor of dermatology at the University of California, San Francisco, and editor in chief of JAMA Dermatology.
 

The wake-up calls

The impetus for current changes first came in 2015, when Bruce Wintroub, MD, professor and chair of dermatology at UCSF, and interim dean of the medical school at the time, delivered a passionate plenary lecture at the annual AAD meeting about the lack of equity, diversity and inclusion in the specialty and the role of unconscious bias. Moved in part by a “White Coats for Black Lives” die-in by medical students on his campus following the killing of unarmed Black men, Dr. Wintroub called on his colleagues to recruit more UIM physicians into the specialty and to make the field more inclusive.

In 2016, Dr. Wintroub joined Dr. Pandya and two other academic dermatologists in authoring a commentary, published in the Journal of the American Academy of Dermatology, about the need to step up efforts and make diversity a priority. Dermatology was among the least ethnically and racially diverse specialties, second only to orthopedics, they wrote, with black dermatologists making up only 3% of all dermatologists and Hispanics only 4.2% in the United States, compared with 12.8% and 16.3% in the U.S. population, respectively.

For the next year or so, they and others from six academic institutions formed an incubator of sorts, actively tracking and sharing actions they were taking to improve diversity and the practice environment. “We wanted to learn from each other, then disseminate information to other programs,” said Dr. Pandya, who chaired the AAD diversity task force and led the self-branded “diversity champions.” (Dr. Pandya maintains his appointment at UTSW but now practices at the Palo Alto Foundation Medical Group in Sunnyvale, Calif.)

In 2017, at a President’s Conference on Diversity in Dermatology called for by then-AAD president Henry Lim, MD, leaders of the Association of Professors of Dermatology, the Society for Investigative Dermatology, and other dermatology organizations agreed on key action items, which they described in JAAD in 2018: Helping to increase the pipeline of UIM students applying to medical school, increasing UIM medical students’ early exposure to dermatology, and increasing the number of UIM students recruited into dermatology residency programs.

Diversity in the physician workforce has been shown to improve outcomes for all patients, and is important for ameliorating health care disparities and improving satisfaction and care for all patients, the authors of the 2018 paper wrote. “Multiple studies,” they noted, “have shown that UIM physicians are more likely to practice in areas where health care disparities exist.”

For specific proposed actions, the leaders attending the diversity conference drew largely upon the “diversity champions’” experiences, and agreed to fund and officially develop a diversity champions program. They also decided to invest in “bioskills” workshops for undergraduates and medical students at historically black colleges and universities, and other institutions at historically black colleges and universities at medical schools through a partnership with Nth Dimension – an organization founded in 2004 to bring more women and underrepresented minorities into orthopedic surgery.

In the last 2 years, more than 450 UIM students have attended these bioskills workshops, getting a taste of basic dermatology procedures and interacting with dermatologists.

And in September 2020, 157 dermatologists representing 80 programs throughout the country attended the second AAD Diversity Champions conference, up from 84 attendees and 30 programs in 2019. On the agenda: Discussions of holistic application review, mentorship, recruitment of UIM faculty, and a 2-hour session on microaggressions. Similar programs are being led by other dermatology organizations.

(UIM was coined by the American Association of Medical Colleges to describe racial and ethnic populations that are underrepresented in medicine relative to their numbers in the general population.)

Achievement of racial/ethnic diversity “won’t happen unless the field actively encourages people to look at it – which is not what we were doing,” Dr. Wintroub said in an interview. “I think that’s been the major change. We’re opening the door and saying: ‘We want you and we welcome you.’ ”


 

Rethinking traditional mentorship

For Dr. Florez-Pollack, the door almost shut when she began to hear from fellow medical students that dermatology is “too competitive ... a field for only the top people in the class.” She felt doubt settling in.

“I had peers who were throwing a lot of money toward prep materials ... peers who had siblings in medicine and had started studying from day one [for the step 1 exam],” she said. “I thought, was it really worth the effort? Do I really want to be perfect to get into the field when other fields would be happy to have me as I am right now?”

Her immense enjoyment of an “Art of Observation” elective course helped renew her interest in the field; it reinforced her visual abilities as well as the potential for her to address implicit bias as a dermatologist. She sought Dr. Pandya’s guidance and sponsorship to help her grow connections, polish her resume, and present herself to other faculty.

Doors were opened, she said, for her to secure a 1-year research experience before her final year of medical school with UTSW faculty, and then a 1-month rotation/mentorship with William D. James, MD, professor of dermatology at the University of Pennsylvania, an institution with a history of diversity initiatives and a longstanding skin of color program.

Dr. Florez-Pollack sees her experience reflected in the findings of a recently published study – a thematic content analysis of telephone interviews with applicants to the UTSW dermatology residency program during the 2013-14 and 2014-15 application cycles. Of the 44 applicants who participated in the study, 13 were UIM applicants.

Six of the seven UIM applicants who matched were involved in a pipeline or enrichment program – and were exposed to the field early – compared with one or two of the six UIM applicants who did not match. Underrepresented applicants were more often discouraged from applying (54%) – told, for instance, that they could better serve their communities through other specialties – than were non-UIM applicants (13%). They also were affected more often by a lack of equitable resources, according to comments made by 70% of applicants (UIM and non-UIM).

Also notably, the investigators said, all of the UIM applicants who matched (and the majority of non-UIMs who matched) reported having a mentor during the process of applying, compared with 44% of those who didn’t match.

Rebecca Vasquez, MD, assistant professor of dermatology at UTSW, who led the study, was herself a mentee of Dr. Pandya. “He believed in me and gave me the courage to consider dermatology,” she said. (Dr. Vasquez was one of the Latinx women who inspired Dr. Florez-Pollack, in turn, when they met at Dr. Pandya’s pizza party. Dr. Florez-Pollack assisted with the research and was a coauthor of the study.)

Amy McMichael, MD, professor and chair of dermatology at Wake Forest University, Winston-Salem, N.C., said that dermatology as a field has traditionally been “very good at mentoring.” Many of the dermatology societies have long had mentorship programs, for instance, that guide medical students, and sometimes residents, through defined experiences or through periods of time.

But she advocates going deeper. “When it comes to sponsorship, we fall a little short,” she said. “Sponsorship is about promoting that person to the next level, making sure they achieve what they want to achieve ... putting them up for opportunities they may not have known existed. It’s continuous and focused.”

Dr. Olabola Awosika

Olabola Awosika, MD, a fourth-year dermatology resident at Henry Ford Health System, Detroit, said her interest in dermatology was solidified during her participation in the AAD’s month-long mentorship program after her second year of medical school at Howard University, Washington. However, it wasn’t until her fourth year, when she did an away rotation at Wake Forest, that she realized that “gaining access to the field” takes years of mentorship, research opportunities, and networking. It was too late.

After initially not matching, she did a rotation at Johns Hopkins in dermatology during an internship year, followed by a 2-year research fellowship at George Washington University, Washington. As does Dr. Florez-Pollack, who now mentors medical students. She also serves on the Women’s Dermatologic Society diversity committee, which is now developing initiatives to help UIM dermatologists “become upwardly mobile in dermatology [after residency], so they have a seat at the table in various settings.”
 

Holistic review for residency

Dr. Vasquez, who grew up in South Texas in an uninsured family that received most of its medical care across the border in Mexico, believes that the “biggest stride being made today” with respect to diversity in the dermatology workforce – and in the larger physician workforce – is increased understanding of the role of social and cultural capital.

Dr. Vasquez?

“We’d never really talked about this concept ... about how, if you don’t have the same upbringing, education, and resources, you’re already behind … and you may not do as well on standardized tests,” she said. “Now people are listening to it and understand it. That’s why more programs are looking at how to practice a more holistic approach to selecting applicants to interview.”

Some dermatology programs – at Wake Forest, UCSF, USC, Vanderbilt, and George Washington University for instance – have eliminated the use of U.S. Medical Licensing Examination step 1 scores and Alpha Omega Alpha Medical Honor Society status as filtering/screening metrics. Some also take a “second look” at UIM applicants.

Overall, those making changes are looking “at everything the applicant brings to the table – their story, their experiences,” said Dr. Elbuluk. “We want to understand the full picture of who they are and their journey to becoming a physician.”

Implicit bias training for members of residency review committees is becoming more common, as is such training across the board in dermatology departments. “We have to bring it to the forefront so that we can create more inclusive environments,” said Sharon E. Albers, MD, a dermatologist at Vanderbilt University Medical Center, Nashville, Tenn., who serves as the dermatology department’s diversity liaison to the medical school, and who, as a former faculty member of Meharry Medical College, remains engaged with the historically black institution.

One of her recent efforts, inspired by participation in the diversity champions program, has been developing pipeline programs to speak to middle and high school students about medicine and dermatology. For now, however, she credits a holistic review process for change. Last year, three of the five matched dermatology residents at Vanderbilt were UIM physicians – unprecedented for the institution, Dr. Albers said, and “evidence that holistic review works if you’re very intentional about it.”

Dr. Vasquez?

Dr. Vasquez has analyzed data from the Accreditation Council of Graduate Medical Education and says that UIM dermatology residents comprised 8.0% of the total in 2019, marking an improvement over the prior 7 years. “We’ve introduced so many changes at the same time,” making it difficult to discern what’s most impactful, she said. “But something is working.”

(The AAMC, which has invested in pipeline programs for more than a decade and has championed holistic medical school admissions, states in its 2019 diversity data report that efforts to improve diversity in medicine have made “only marginal differences” – and that Black males in particular continue to be significantly underrepresented in medical schools. Persistent, structural racism was a common theme in the association’s 2015 report on Black males in medicine.)

Efforts to diversify the workforce – particularly holistic review – haven’t been without detractors. “It brings reaction,” Dr. Wintroub said. “Some people think you’re lowering quality in the field ... but that’s just not true.”

Diversity in the dermatology workforce is important not only for the care of patients from diverse backgrounds, but “perhaps more importantly, it brings new ideas and views and experiences into the field,” he said. “It pushes us to think in new directions ... that can only make our field better and richer.”

“We need to make sure our workforce is representative of the patients we serve – but also that all derms can manage patients of all skin types and demographics,” Dr. Shinkai said. “And we need more diversity in the leadership of our departments and dermatology organizations ... inclusivity needs to extend all the way to the highest reaches of our specialty.”

Adam Friedman, MD, professor and interim chair of dermatology at George Washington University and director of the department’s diversity, equity, and inclusion committee, agreed. “We need to both make sure our workforce mirrors the patients we serve, and said workforce is prepared to manage patients of all skin types and demographics. We need to cover the spectrum, from revamping medical education and mentorship opportunities to advancing diversity in the leadership of our departments, institutions, and societies. Addressing only part of the puzzle will not and can not be enough.”

Correction, 3/3/21: An earlier version of this article misstated Dr. Stephanie Florez-Pollack's name.

Stephanie Florez-Pollack, MD, a dermatology resident at the University of Pennsylvania, Philadelphia, began considering the field of dermatology when, as part of the Latino Medical Students Association, she was invited by Amit Pandya, MD, to a pizza party and dermatology discussion during her first year of medical school at the University of Texas Southwestern Medical Center, Dallas.

Courtesy Dr. Stephanie Flores-Pollack

There, she met three Latinx residents who were part of the University of Texas Southwestern dermatology program. “I was so excited to hear their stories, where they came from, and how they ended up in dermatology,” she said. Dermatology had not been on her radar screen. Now there was a spark.

Volunteering at the free Agape dermatology clinic in Dallas later that year sharpened her interest. “For the first time, I really saw myself working in the field. Hearing patients’ stories and what they went through with what many people might think are very simple skin diseases made me realize there was potential to make a big impact in a person’s life,” said Dr. Florez-Pollack, who immigrated from Colombia with her family when she was 15.

Dr. Florez-Pollack’s journey into dermatology as an underrepresented-in-medicine (UIM) physician-in-training offers a window into a movement underway that aims to create a diverse dermatology workforce – one that reflects the ethnic and racial make-up of the population. It’s a movement that involves early outreach to medical students, stepped-up mentorship and sponsorship, implicit bias training, and holistic review of residency applicants.

There is no published study of all the changes being made – of how many dermatology programs have new outreach programs, for instance, or new approaches to resident application reviews. However, participation in the American Academy of Dermatology Diversity Champions program increased significantly between 2019 and 2020, and a sizable body of articles and editorials on diversity have been published in the dermatology literature in recent years, including at least several on holistic review of resident applications. Five years ago, there were few publications, sources said.

“The conversation is happening now at multiple levels, including in our peer-reviewed literature, where people are looking objectively at ... how we can make changes for the better,” said Nada Elbuluk, MD, director of the dermatology diversity and inclusion program at the University of Southern California, Los Angeles.

Unpublished findings also indicate that the number of UIM dermatology residents is inching upward. “Residency selection may not be on everyone’s mind, but an understanding of how we select people into our specialty is something every derm should know about and care about,” said Kanade Shinkai, MD, PhD, professor of dermatology at the University of California, San Francisco, and editor in chief of JAMA Dermatology.
 

The wake-up calls

The impetus for current changes first came in 2015, when Bruce Wintroub, MD, professor and chair of dermatology at UCSF, and interim dean of the medical school at the time, delivered a passionate plenary lecture at the annual AAD meeting about the lack of equity, diversity and inclusion in the specialty and the role of unconscious bias. Moved in part by a “White Coats for Black Lives” die-in by medical students on his campus following the killing of unarmed Black men, Dr. Wintroub called on his colleagues to recruit more UIM physicians into the specialty and to make the field more inclusive.

In 2016, Dr. Wintroub joined Dr. Pandya and two other academic dermatologists in authoring a commentary, published in the Journal of the American Academy of Dermatology, about the need to step up efforts and make diversity a priority. Dermatology was among the least ethnically and racially diverse specialties, second only to orthopedics, they wrote, with black dermatologists making up only 3% of all dermatologists and Hispanics only 4.2% in the United States, compared with 12.8% and 16.3% in the U.S. population, respectively.

For the next year or so, they and others from six academic institutions formed an incubator of sorts, actively tracking and sharing actions they were taking to improve diversity and the practice environment. “We wanted to learn from each other, then disseminate information to other programs,” said Dr. Pandya, who chaired the AAD diversity task force and led the self-branded “diversity champions.” (Dr. Pandya maintains his appointment at UTSW but now practices at the Palo Alto Foundation Medical Group in Sunnyvale, Calif.)

In 2017, at a President’s Conference on Diversity in Dermatology called for by then-AAD president Henry Lim, MD, leaders of the Association of Professors of Dermatology, the Society for Investigative Dermatology, and other dermatology organizations agreed on key action items, which they described in JAAD in 2018: Helping to increase the pipeline of UIM students applying to medical school, increasing UIM medical students’ early exposure to dermatology, and increasing the number of UIM students recruited into dermatology residency programs.

Diversity in the physician workforce has been shown to improve outcomes for all patients, and is important for ameliorating health care disparities and improving satisfaction and care for all patients, the authors of the 2018 paper wrote. “Multiple studies,” they noted, “have shown that UIM physicians are more likely to practice in areas where health care disparities exist.”

For specific proposed actions, the leaders attending the diversity conference drew largely upon the “diversity champions’” experiences, and agreed to fund and officially develop a diversity champions program. They also decided to invest in “bioskills” workshops for undergraduates and medical students at historically black colleges and universities, and other institutions at historically black colleges and universities at medical schools through a partnership with Nth Dimension – an organization founded in 2004 to bring more women and underrepresented minorities into orthopedic surgery.

In the last 2 years, more than 450 UIM students have attended these bioskills workshops, getting a taste of basic dermatology procedures and interacting with dermatologists.

And in September 2020, 157 dermatologists representing 80 programs throughout the country attended the second AAD Diversity Champions conference, up from 84 attendees and 30 programs in 2019. On the agenda: Discussions of holistic application review, mentorship, recruitment of UIM faculty, and a 2-hour session on microaggressions. Similar programs are being led by other dermatology organizations.

(UIM was coined by the American Association of Medical Colleges to describe racial and ethnic populations that are underrepresented in medicine relative to their numbers in the general population.)

Achievement of racial/ethnic diversity “won’t happen unless the field actively encourages people to look at it – which is not what we were doing,” Dr. Wintroub said in an interview. “I think that’s been the major change. We’re opening the door and saying: ‘We want you and we welcome you.’ ”


 

Rethinking traditional mentorship

For Dr. Florez-Pollack, the door almost shut when she began to hear from fellow medical students that dermatology is “too competitive ... a field for only the top people in the class.” She felt doubt settling in.

“I had peers who were throwing a lot of money toward prep materials ... peers who had siblings in medicine and had started studying from day one [for the step 1 exam],” she said. “I thought, was it really worth the effort? Do I really want to be perfect to get into the field when other fields would be happy to have me as I am right now?”

Her immense enjoyment of an “Art of Observation” elective course helped renew her interest in the field; it reinforced her visual abilities as well as the potential for her to address implicit bias as a dermatologist. She sought Dr. Pandya’s guidance and sponsorship to help her grow connections, polish her resume, and present herself to other faculty.

Doors were opened, she said, for her to secure a 1-year research experience before her final year of medical school with UTSW faculty, and then a 1-month rotation/mentorship with William D. James, MD, professor of dermatology at the University of Pennsylvania, an institution with a history of diversity initiatives and a longstanding skin of color program.

Dr. Florez-Pollack sees her experience reflected in the findings of a recently published study – a thematic content analysis of telephone interviews with applicants to the UTSW dermatology residency program during the 2013-14 and 2014-15 application cycles. Of the 44 applicants who participated in the study, 13 were UIM applicants.

Six of the seven UIM applicants who matched were involved in a pipeline or enrichment program – and were exposed to the field early – compared with one or two of the six UIM applicants who did not match. Underrepresented applicants were more often discouraged from applying (54%) – told, for instance, that they could better serve their communities through other specialties – than were non-UIM applicants (13%). They also were affected more often by a lack of equitable resources, according to comments made by 70% of applicants (UIM and non-UIM).

Also notably, the investigators said, all of the UIM applicants who matched (and the majority of non-UIMs who matched) reported having a mentor during the process of applying, compared with 44% of those who didn’t match.

Rebecca Vasquez, MD, assistant professor of dermatology at UTSW, who led the study, was herself a mentee of Dr. Pandya. “He believed in me and gave me the courage to consider dermatology,” she said. (Dr. Vasquez was one of the Latinx women who inspired Dr. Florez-Pollack, in turn, when they met at Dr. Pandya’s pizza party. Dr. Florez-Pollack assisted with the research and was a coauthor of the study.)

Amy McMichael, MD, professor and chair of dermatology at Wake Forest University, Winston-Salem, N.C., said that dermatology as a field has traditionally been “very good at mentoring.” Many of the dermatology societies have long had mentorship programs, for instance, that guide medical students, and sometimes residents, through defined experiences or through periods of time.

But she advocates going deeper. “When it comes to sponsorship, we fall a little short,” she said. “Sponsorship is about promoting that person to the next level, making sure they achieve what they want to achieve ... putting them up for opportunities they may not have known existed. It’s continuous and focused.”

Dr. Olabola Awosika

Olabola Awosika, MD, a fourth-year dermatology resident at Henry Ford Health System, Detroit, said her interest in dermatology was solidified during her participation in the AAD’s month-long mentorship program after her second year of medical school at Howard University, Washington. However, it wasn’t until her fourth year, when she did an away rotation at Wake Forest, that she realized that “gaining access to the field” takes years of mentorship, research opportunities, and networking. It was too late.

After initially not matching, she did a rotation at Johns Hopkins in dermatology during an internship year, followed by a 2-year research fellowship at George Washington University, Washington. As does Dr. Florez-Pollack, who now mentors medical students. She also serves on the Women’s Dermatologic Society diversity committee, which is now developing initiatives to help UIM dermatologists “become upwardly mobile in dermatology [after residency], so they have a seat at the table in various settings.”
 

Holistic review for residency

Dr. Vasquez, who grew up in South Texas in an uninsured family that received most of its medical care across the border in Mexico, believes that the “biggest stride being made today” with respect to diversity in the dermatology workforce – and in the larger physician workforce – is increased understanding of the role of social and cultural capital.

Dr. Vasquez?

“We’d never really talked about this concept ... about how, if you don’t have the same upbringing, education, and resources, you’re already behind … and you may not do as well on standardized tests,” she said. “Now people are listening to it and understand it. That’s why more programs are looking at how to practice a more holistic approach to selecting applicants to interview.”

Some dermatology programs – at Wake Forest, UCSF, USC, Vanderbilt, and George Washington University for instance – have eliminated the use of U.S. Medical Licensing Examination step 1 scores and Alpha Omega Alpha Medical Honor Society status as filtering/screening metrics. Some also take a “second look” at UIM applicants.

Overall, those making changes are looking “at everything the applicant brings to the table – their story, their experiences,” said Dr. Elbuluk. “We want to understand the full picture of who they are and their journey to becoming a physician.”

Implicit bias training for members of residency review committees is becoming more common, as is such training across the board in dermatology departments. “We have to bring it to the forefront so that we can create more inclusive environments,” said Sharon E. Albers, MD, a dermatologist at Vanderbilt University Medical Center, Nashville, Tenn., who serves as the dermatology department’s diversity liaison to the medical school, and who, as a former faculty member of Meharry Medical College, remains engaged with the historically black institution.

One of her recent efforts, inspired by participation in the diversity champions program, has been developing pipeline programs to speak to middle and high school students about medicine and dermatology. For now, however, she credits a holistic review process for change. Last year, three of the five matched dermatology residents at Vanderbilt were UIM physicians – unprecedented for the institution, Dr. Albers said, and “evidence that holistic review works if you’re very intentional about it.”

Dr. Vasquez?

Dr. Vasquez has analyzed data from the Accreditation Council of Graduate Medical Education and says that UIM dermatology residents comprised 8.0% of the total in 2019, marking an improvement over the prior 7 years. “We’ve introduced so many changes at the same time,” making it difficult to discern what’s most impactful, she said. “But something is working.”

(The AAMC, which has invested in pipeline programs for more than a decade and has championed holistic medical school admissions, states in its 2019 diversity data report that efforts to improve diversity in medicine have made “only marginal differences” – and that Black males in particular continue to be significantly underrepresented in medical schools. Persistent, structural racism was a common theme in the association’s 2015 report on Black males in medicine.)

Efforts to diversify the workforce – particularly holistic review – haven’t been without detractors. “It brings reaction,” Dr. Wintroub said. “Some people think you’re lowering quality in the field ... but that’s just not true.”

Diversity in the dermatology workforce is important not only for the care of patients from diverse backgrounds, but “perhaps more importantly, it brings new ideas and views and experiences into the field,” he said. “It pushes us to think in new directions ... that can only make our field better and richer.”

“We need to make sure our workforce is representative of the patients we serve – but also that all derms can manage patients of all skin types and demographics,” Dr. Shinkai said. “And we need more diversity in the leadership of our departments and dermatology organizations ... inclusivity needs to extend all the way to the highest reaches of our specialty.”

Adam Friedman, MD, professor and interim chair of dermatology at George Washington University and director of the department’s diversity, equity, and inclusion committee, agreed. “We need to both make sure our workforce mirrors the patients we serve, and said workforce is prepared to manage patients of all skin types and demographics. We need to cover the spectrum, from revamping medical education and mentorship opportunities to advancing diversity in the leadership of our departments, institutions, and societies. Addressing only part of the puzzle will not and can not be enough.”

Correction, 3/3/21: An earlier version of this article misstated Dr. Stephanie Florez-Pollack's name.

Stephanie Florez-Pollack, MD, a dermatology resident at the University of Pennsylvania, Philadelphia, began considering the field of dermatology when, as part of the Latino Medical Students Association, she was invited by Amit Pandya, MD, to a pizza party and dermatology discussion during her first year of medical school at the University of Texas Southwestern Medical Center, Dallas.

Courtesy Dr. Stephanie Flores-Pollack

There, she met three Latinx residents who were part of the University of Texas Southwestern dermatology program. “I was so excited to hear their stories, where they came from, and how they ended up in dermatology,” she said. Dermatology had not been on her radar screen. Now there was a spark.

Volunteering at the free Agape dermatology clinic in Dallas later that year sharpened her interest. “For the first time, I really saw myself working in the field. Hearing patients’ stories and what they went through with what many people might think are very simple skin diseases made me realize there was potential to make a big impact in a person’s life,” said Dr. Florez-Pollack, who immigrated from Colombia with her family when she was 15.

Dr. Florez-Pollack’s journey into dermatology as an underrepresented-in-medicine (UIM) physician-in-training offers a window into a movement underway that aims to create a diverse dermatology workforce – one that reflects the ethnic and racial make-up of the population. It’s a movement that involves early outreach to medical students, stepped-up mentorship and sponsorship, implicit bias training, and holistic review of residency applicants.

There is no published study of all the changes being made – of how many dermatology programs have new outreach programs, for instance, or new approaches to resident application reviews. However, participation in the American Academy of Dermatology Diversity Champions program increased significantly between 2019 and 2020, and a sizable body of articles and editorials on diversity have been published in the dermatology literature in recent years, including at least several on holistic review of resident applications. Five years ago, there were few publications, sources said.

“The conversation is happening now at multiple levels, including in our peer-reviewed literature, where people are looking objectively at ... how we can make changes for the better,” said Nada Elbuluk, MD, director of the dermatology diversity and inclusion program at the University of Southern California, Los Angeles.

Unpublished findings also indicate that the number of UIM dermatology residents is inching upward. “Residency selection may not be on everyone’s mind, but an understanding of how we select people into our specialty is something every derm should know about and care about,” said Kanade Shinkai, MD, PhD, professor of dermatology at the University of California, San Francisco, and editor in chief of JAMA Dermatology.
 

The wake-up calls

The impetus for current changes first came in 2015, when Bruce Wintroub, MD, professor and chair of dermatology at UCSF, and interim dean of the medical school at the time, delivered a passionate plenary lecture at the annual AAD meeting about the lack of equity, diversity and inclusion in the specialty and the role of unconscious bias. Moved in part by a “White Coats for Black Lives” die-in by medical students on his campus following the killing of unarmed Black men, Dr. Wintroub called on his colleagues to recruit more UIM physicians into the specialty and to make the field more inclusive.

In 2016, Dr. Wintroub joined Dr. Pandya and two other academic dermatologists in authoring a commentary, published in the Journal of the American Academy of Dermatology, about the need to step up efforts and make diversity a priority. Dermatology was among the least ethnically and racially diverse specialties, second only to orthopedics, they wrote, with black dermatologists making up only 3% of all dermatologists and Hispanics only 4.2% in the United States, compared with 12.8% and 16.3% in the U.S. population, respectively.

For the next year or so, they and others from six academic institutions formed an incubator of sorts, actively tracking and sharing actions they were taking to improve diversity and the practice environment. “We wanted to learn from each other, then disseminate information to other programs,” said Dr. Pandya, who chaired the AAD diversity task force and led the self-branded “diversity champions.” (Dr. Pandya maintains his appointment at UTSW but now practices at the Palo Alto Foundation Medical Group in Sunnyvale, Calif.)

In 2017, at a President’s Conference on Diversity in Dermatology called for by then-AAD president Henry Lim, MD, leaders of the Association of Professors of Dermatology, the Society for Investigative Dermatology, and other dermatology organizations agreed on key action items, which they described in JAAD in 2018: Helping to increase the pipeline of UIM students applying to medical school, increasing UIM medical students’ early exposure to dermatology, and increasing the number of UIM students recruited into dermatology residency programs.

Diversity in the physician workforce has been shown to improve outcomes for all patients, and is important for ameliorating health care disparities and improving satisfaction and care for all patients, the authors of the 2018 paper wrote. “Multiple studies,” they noted, “have shown that UIM physicians are more likely to practice in areas where health care disparities exist.”

For specific proposed actions, the leaders attending the diversity conference drew largely upon the “diversity champions’” experiences, and agreed to fund and officially develop a diversity champions program. They also decided to invest in “bioskills” workshops for undergraduates and medical students at historically black colleges and universities, and other institutions at historically black colleges and universities at medical schools through a partnership with Nth Dimension – an organization founded in 2004 to bring more women and underrepresented minorities into orthopedic surgery.

In the last 2 years, more than 450 UIM students have attended these bioskills workshops, getting a taste of basic dermatology procedures and interacting with dermatologists.

And in September 2020, 157 dermatologists representing 80 programs throughout the country attended the second AAD Diversity Champions conference, up from 84 attendees and 30 programs in 2019. On the agenda: Discussions of holistic application review, mentorship, recruitment of UIM faculty, and a 2-hour session on microaggressions. Similar programs are being led by other dermatology organizations.

(UIM was coined by the American Association of Medical Colleges to describe racial and ethnic populations that are underrepresented in medicine relative to their numbers in the general population.)

Achievement of racial/ethnic diversity “won’t happen unless the field actively encourages people to look at it – which is not what we were doing,” Dr. Wintroub said in an interview. “I think that’s been the major change. We’re opening the door and saying: ‘We want you and we welcome you.’ ”


 

Rethinking traditional mentorship

For Dr. Florez-Pollack, the door almost shut when she began to hear from fellow medical students that dermatology is “too competitive ... a field for only the top people in the class.” She felt doubt settling in.

“I had peers who were throwing a lot of money toward prep materials ... peers who had siblings in medicine and had started studying from day one [for the step 1 exam],” she said. “I thought, was it really worth the effort? Do I really want to be perfect to get into the field when other fields would be happy to have me as I am right now?”

Her immense enjoyment of an “Art of Observation” elective course helped renew her interest in the field; it reinforced her visual abilities as well as the potential for her to address implicit bias as a dermatologist. She sought Dr. Pandya’s guidance and sponsorship to help her grow connections, polish her resume, and present herself to other faculty.

Doors were opened, she said, for her to secure a 1-year research experience before her final year of medical school with UTSW faculty, and then a 1-month rotation/mentorship with William D. James, MD, professor of dermatology at the University of Pennsylvania, an institution with a history of diversity initiatives and a longstanding skin of color program.

Dr. Florez-Pollack sees her experience reflected in the findings of a recently published study – a thematic content analysis of telephone interviews with applicants to the UTSW dermatology residency program during the 2013-14 and 2014-15 application cycles. Of the 44 applicants who participated in the study, 13 were UIM applicants.

Six of the seven UIM applicants who matched were involved in a pipeline or enrichment program – and were exposed to the field early – compared with one or two of the six UIM applicants who did not match. Underrepresented applicants were more often discouraged from applying (54%) – told, for instance, that they could better serve their communities through other specialties – than were non-UIM applicants (13%). They also were affected more often by a lack of equitable resources, according to comments made by 70% of applicants (UIM and non-UIM).

Also notably, the investigators said, all of the UIM applicants who matched (and the majority of non-UIMs who matched) reported having a mentor during the process of applying, compared with 44% of those who didn’t match.

Rebecca Vasquez, MD, assistant professor of dermatology at UTSW, who led the study, was herself a mentee of Dr. Pandya. “He believed in me and gave me the courage to consider dermatology,” she said. (Dr. Vasquez was one of the Latinx women who inspired Dr. Florez-Pollack, in turn, when they met at Dr. Pandya’s pizza party. Dr. Florez-Pollack assisted with the research and was a coauthor of the study.)

Amy McMichael, MD, professor and chair of dermatology at Wake Forest University, Winston-Salem, N.C., said that dermatology as a field has traditionally been “very good at mentoring.” Many of the dermatology societies have long had mentorship programs, for instance, that guide medical students, and sometimes residents, through defined experiences or through periods of time.

But she advocates going deeper. “When it comes to sponsorship, we fall a little short,” she said. “Sponsorship is about promoting that person to the next level, making sure they achieve what they want to achieve ... putting them up for opportunities they may not have known existed. It’s continuous and focused.”

Dr. Olabola Awosika

Olabola Awosika, MD, a fourth-year dermatology resident at Henry Ford Health System, Detroit, said her interest in dermatology was solidified during her participation in the AAD’s month-long mentorship program after her second year of medical school at Howard University, Washington. However, it wasn’t until her fourth year, when she did an away rotation at Wake Forest, that she realized that “gaining access to the field” takes years of mentorship, research opportunities, and networking. It was too late.

After initially not matching, she did a rotation at Johns Hopkins in dermatology during an internship year, followed by a 2-year research fellowship at George Washington University, Washington. As does Dr. Florez-Pollack, who now mentors medical students. She also serves on the Women’s Dermatologic Society diversity committee, which is now developing initiatives to help UIM dermatologists “become upwardly mobile in dermatology [after residency], so they have a seat at the table in various settings.”
 

Holistic review for residency

Dr. Vasquez, who grew up in South Texas in an uninsured family that received most of its medical care across the border in Mexico, believes that the “biggest stride being made today” with respect to diversity in the dermatology workforce – and in the larger physician workforce – is increased understanding of the role of social and cultural capital.

Dr. Vasquez?

“We’d never really talked about this concept ... about how, if you don’t have the same upbringing, education, and resources, you’re already behind … and you may not do as well on standardized tests,” she said. “Now people are listening to it and understand it. That’s why more programs are looking at how to practice a more holistic approach to selecting applicants to interview.”

Some dermatology programs – at Wake Forest, UCSF, USC, Vanderbilt, and George Washington University for instance – have eliminated the use of U.S. Medical Licensing Examination step 1 scores and Alpha Omega Alpha Medical Honor Society status as filtering/screening metrics. Some also take a “second look” at UIM applicants.

Overall, those making changes are looking “at everything the applicant brings to the table – their story, their experiences,” said Dr. Elbuluk. “We want to understand the full picture of who they are and their journey to becoming a physician.”

Implicit bias training for members of residency review committees is becoming more common, as is such training across the board in dermatology departments. “We have to bring it to the forefront so that we can create more inclusive environments,” said Sharon E. Albers, MD, a dermatologist at Vanderbilt University Medical Center, Nashville, Tenn., who serves as the dermatology department’s diversity liaison to the medical school, and who, as a former faculty member of Meharry Medical College, remains engaged with the historically black institution.

One of her recent efforts, inspired by participation in the diversity champions program, has been developing pipeline programs to speak to middle and high school students about medicine and dermatology. For now, however, she credits a holistic review process for change. Last year, three of the five matched dermatology residents at Vanderbilt were UIM physicians – unprecedented for the institution, Dr. Albers said, and “evidence that holistic review works if you’re very intentional about it.”

Dr. Vasquez?

Dr. Vasquez has analyzed data from the Accreditation Council of Graduate Medical Education and says that UIM dermatology residents comprised 8.0% of the total in 2019, marking an improvement over the prior 7 years. “We’ve introduced so many changes at the same time,” making it difficult to discern what’s most impactful, she said. “But something is working.”

(The AAMC, which has invested in pipeline programs for more than a decade and has championed holistic medical school admissions, states in its 2019 diversity data report that efforts to improve diversity in medicine have made “only marginal differences” – and that Black males in particular continue to be significantly underrepresented in medical schools. Persistent, structural racism was a common theme in the association’s 2015 report on Black males in medicine.)

Efforts to diversify the workforce – particularly holistic review – haven’t been without detractors. “It brings reaction,” Dr. Wintroub said. “Some people think you’re lowering quality in the field ... but that’s just not true.”

Diversity in the dermatology workforce is important not only for the care of patients from diverse backgrounds, but “perhaps more importantly, it brings new ideas and views and experiences into the field,” he said. “It pushes us to think in new directions ... that can only make our field better and richer.”

“We need to make sure our workforce is representative of the patients we serve – but also that all derms can manage patients of all skin types and demographics,” Dr. Shinkai said. “And we need more diversity in the leadership of our departments and dermatology organizations ... inclusivity needs to extend all the way to the highest reaches of our specialty.”

Adam Friedman, MD, professor and interim chair of dermatology at George Washington University and director of the department’s diversity, equity, and inclusion committee, agreed. “We need to both make sure our workforce mirrors the patients we serve, and said workforce is prepared to manage patients of all skin types and demographics. We need to cover the spectrum, from revamping medical education and mentorship opportunities to advancing diversity in the leadership of our departments, institutions, and societies. Addressing only part of the puzzle will not and can not be enough.”

Correction, 3/3/21: An earlier version of this article misstated Dr. Stephanie Florez-Pollack's name.

Black women are significantly more likely than non-Black women to develop major depression within a month of early pregnancy loss, based on data from a secondary analysis of 300 women.

Approximately 25% of women experience a pregnancy loss, and many of these women are at increased risk for psychological problems including major depression, wrote Jade M. Shorter, MD, of Stanford (Calif.) University, and colleagues.

Data from previous studies show that Black women experience higher rates of perinatal depression, compared with other racial groups, and that stress and adverse childhood experiences also are higher among Black individuals, they noted.

“Based on data showing higher rates of pregnancy loss, perinatal depression, and perceived stress in Black women, we hypothesized that the odds of having risk for major depression or high perceived stress 30 days after miscarriage treatment would be higher in Black participants when compared with non-Black participants,” they wrote.

In a study published in Obstetrics & Gynecology, the researchers conducted a secondary analysis of 300 women aged 18 years and older with nonviable intrauterine pregnancy between 5 and 12 weeks’ gestation who were part of a larger randomized trial conducted between May 2014 and April 2017. The women were randomized to medical treatment of either mifepristone 200 mg orally plus misoprostol 800 mcg vaginally after 24 hours or the usual treatment of misoprostol 800 mcg vaginally.

Depression was assessed using the Center for Epidemiological Studies–Depression scale, Perceived Stress Scale, and Adverse Childhood Experience scale. Adverse childhood experience data were collected at baseline; stress and depression data were collected at baseline and at 30 days after treatment.

A total of 120 participants self-identified as Black and 155 self-identified as non-Black.
 

Depression risk doubles in Black women

At 30 days after treatment for early pregnancy loss, 24% of women met criteria for major depression, including 57% of Black women and 43% of non-Black women. The odds of depression were twice as high among Black women, compared with non-Black women (odds ratio 2.02), and Black women were more likely to be younger, have lower levels of education, and have public insurance, compared with non-Black women.

The association between Black race and increased risk for depression at 30 days after treatment persisted after controlling for factors including parity, baseline depression, and adverse childhood experiences, the researchers noted.

The study findings were limited by several factors, including the potential for different depression risk in those from the original study who did and did not participate in the secondary analysis and by the use of the original Adverse Childhood Experience survey, which may not reflect the range of adversity faced by different demographic groups, the researchers noted. However, the results were strengthened by the collection of 30-day outcome data in the clinical setting and by the diverse study population.

“These findings should be not be used to stigmatize Black women; instead, it is important to consider the complex systemic factors, such as structural racism, that are the root causes of disparate health outcomes,” and to support appropriate mental health resources and interventions for all women who experience early pregnancy loss, the researchers emphasized.
 

Recognize risks, reduce barriers

“Early pregnancy loss is unfortunately a common event that affects 15%-20% of pregnancies,” Iris Krishna, MD, of Emory University, Atlanta, said in an interview.

However, “the mental health impact of early pregnancy loss is understudied, and as a result mental health disorders often go unnoticed and untreated,” she said.

Growing evidence shows that Black women in particular are at greater risk for chronic stressors that affect their overall health. “Black women are more likely to be exposed to trauma in their lifetime, such as physical and emotional abuse, neglect, and household instability, all of which predispose women to mental health disorders such as depression. Untreated maternal depression has an impact on future pregnancy outcomes such as increasing the risk of having a preterm delivery and/or delivering a low-birth-weight baby, outcomes where Black women are at disproportionately high risk in comparison to non-Black women,” Dr. Krishna said.

“This study found that the risk for depression after an early pregnancy loss is twice as high for Black women in comparison to non-Black women. The findings of this study further underscore the fact that Black women are at disproportionate high risk for poor maternal and pregnancy outcomes,” Dr. Krishna added.

“Structural racism is a major barrier to caring for the health of Black women. To care for the health of Black women we must overcome racial and ethnic disparities. Addressing disparities involves a multitiered approach, including identifying and addressing implicit bias in health care and improving access to health care for women of color,” she said.

“Additional research is needed in identifying at-risk women and mental health interventions that can improve the mental well-being of women after adverse pregnancy outcomes such as early pregnancy loss,” Dr. Krishna concluded.

The study was supported by the Society of Family Planning Research Fund. Lead author Dr. Shorter had no financial conflicts to disclose. Dr. Krishna had no financial conflicts to disclose.

SOURCE: Shorter JM et al. Obstet Gynecol. 2020 Dec 3. doi: 10.1097/AOG.0000000000004212.

Black women are significantly more likely than non-Black women to develop major depression within a month of early pregnancy loss, based on data from a secondary analysis of 300 women.

Approximately 25% of women experience a pregnancy loss, and many of these women are at increased risk for psychological problems including major depression, wrote Jade M. Shorter, MD, of Stanford (Calif.) University, and colleagues.

Data from previous studies show that Black women experience higher rates of perinatal depression, compared with other racial groups, and that stress and adverse childhood experiences also are higher among Black individuals, they noted.

“Based on data showing higher rates of pregnancy loss, perinatal depression, and perceived stress in Black women, we hypothesized that the odds of having risk for major depression or high perceived stress 30 days after miscarriage treatment would be higher in Black participants when compared with non-Black participants,” they wrote.

In a study published in Obstetrics & Gynecology, the researchers conducted a secondary analysis of 300 women aged 18 years and older with nonviable intrauterine pregnancy between 5 and 12 weeks’ gestation who were part of a larger randomized trial conducted between May 2014 and April 2017. The women were randomized to medical treatment of either mifepristone 200 mg orally plus misoprostol 800 mcg vaginally after 24 hours or the usual treatment of misoprostol 800 mcg vaginally.

Depression was assessed using the Center for Epidemiological Studies–Depression scale, Perceived Stress Scale, and Adverse Childhood Experience scale. Adverse childhood experience data were collected at baseline; stress and depression data were collected at baseline and at 30 days after treatment.

A total of 120 participants self-identified as Black and 155 self-identified as non-Black.
 

Depression risk doubles in Black women

At 30 days after treatment for early pregnancy loss, 24% of women met criteria for major depression, including 57% of Black women and 43% of non-Black women. The odds of depression were twice as high among Black women, compared with non-Black women (odds ratio 2.02), and Black women were more likely to be younger, have lower levels of education, and have public insurance, compared with non-Black women.

The association between Black race and increased risk for depression at 30 days after treatment persisted after controlling for factors including parity, baseline depression, and adverse childhood experiences, the researchers noted.

The study findings were limited by several factors, including the potential for different depression risk in those from the original study who did and did not participate in the secondary analysis and by the use of the original Adverse Childhood Experience survey, which may not reflect the range of adversity faced by different demographic groups, the researchers noted. However, the results were strengthened by the collection of 30-day outcome data in the clinical setting and by the diverse study population.

“These findings should be not be used to stigmatize Black women; instead, it is important to consider the complex systemic factors, such as structural racism, that are the root causes of disparate health outcomes,” and to support appropriate mental health resources and interventions for all women who experience early pregnancy loss, the researchers emphasized.
 

Recognize risks, reduce barriers

“Early pregnancy loss is unfortunately a common event that affects 15%-20% of pregnancies,” Iris Krishna, MD, of Emory University, Atlanta, said in an interview.

However, “the mental health impact of early pregnancy loss is understudied, and as a result mental health disorders often go unnoticed and untreated,” she said.

Growing evidence shows that Black women in particular are at greater risk for chronic stressors that affect their overall health. “Black women are more likely to be exposed to trauma in their lifetime, such as physical and emotional abuse, neglect, and household instability, all of which predispose women to mental health disorders such as depression. Untreated maternal depression has an impact on future pregnancy outcomes such as increasing the risk of having a preterm delivery and/or delivering a low-birth-weight baby, outcomes where Black women are at disproportionately high risk in comparison to non-Black women,” Dr. Krishna said.

“This study found that the risk for depression after an early pregnancy loss is twice as high for Black women in comparison to non-Black women. The findings of this study further underscore the fact that Black women are at disproportionate high risk for poor maternal and pregnancy outcomes,” Dr. Krishna added.

“Structural racism is a major barrier to caring for the health of Black women. To care for the health of Black women we must overcome racial and ethnic disparities. Addressing disparities involves a multitiered approach, including identifying and addressing implicit bias in health care and improving access to health care for women of color,” she said.

“Additional research is needed in identifying at-risk women and mental health interventions that can improve the mental well-being of women after adverse pregnancy outcomes such as early pregnancy loss,” Dr. Krishna concluded.

The study was supported by the Society of Family Planning Research Fund. Lead author Dr. Shorter had no financial conflicts to disclose. Dr. Krishna had no financial conflicts to disclose.

SOURCE: Shorter JM et al. Obstet Gynecol. 2020 Dec 3. doi: 10.1097/AOG.0000000000004212.

Black women are significantly more likely than non-Black women to develop major depression within a month of early pregnancy loss, based on data from a secondary analysis of 300 women.

Approximately 25% of women experience a pregnancy loss, and many of these women are at increased risk for psychological problems including major depression, wrote Jade M. Shorter, MD, of Stanford (Calif.) University, and colleagues.

Data from previous studies show that Black women experience higher rates of perinatal depression, compared with other racial groups, and that stress and adverse childhood experiences also are higher among Black individuals, they noted.

“Based on data showing higher rates of pregnancy loss, perinatal depression, and perceived stress in Black women, we hypothesized that the odds of having risk for major depression or high perceived stress 30 days after miscarriage treatment would be higher in Black participants when compared with non-Black participants,” they wrote.

In a study published in Obstetrics & Gynecology, the researchers conducted a secondary analysis of 300 women aged 18 years and older with nonviable intrauterine pregnancy between 5 and 12 weeks’ gestation who were part of a larger randomized trial conducted between May 2014 and April 2017. The women were randomized to medical treatment of either mifepristone 200 mg orally plus misoprostol 800 mcg vaginally after 24 hours or the usual treatment of misoprostol 800 mcg vaginally.

Depression was assessed using the Center for Epidemiological Studies–Depression scale, Perceived Stress Scale, and Adverse Childhood Experience scale. Adverse childhood experience data were collected at baseline; stress and depression data were collected at baseline and at 30 days after treatment.

A total of 120 participants self-identified as Black and 155 self-identified as non-Black.
 

Depression risk doubles in Black women

At 30 days after treatment for early pregnancy loss, 24% of women met criteria for major depression, including 57% of Black women and 43% of non-Black women. The odds of depression were twice as high among Black women, compared with non-Black women (odds ratio 2.02), and Black women were more likely to be younger, have lower levels of education, and have public insurance, compared with non-Black women.

The association between Black race and increased risk for depression at 30 days after treatment persisted after controlling for factors including parity, baseline depression, and adverse childhood experiences, the researchers noted.

The study findings were limited by several factors, including the potential for different depression risk in those from the original study who did and did not participate in the secondary analysis and by the use of the original Adverse Childhood Experience survey, which may not reflect the range of adversity faced by different demographic groups, the researchers noted. However, the results were strengthened by the collection of 30-day outcome data in the clinical setting and by the diverse study population.

“These findings should be not be used to stigmatize Black women; instead, it is important to consider the complex systemic factors, such as structural racism, that are the root causes of disparate health outcomes,” and to support appropriate mental health resources and interventions for all women who experience early pregnancy loss, the researchers emphasized.
 

Recognize risks, reduce barriers

“Early pregnancy loss is unfortunately a common event that affects 15%-20% of pregnancies,” Iris Krishna, MD, of Emory University, Atlanta, said in an interview.

However, “the mental health impact of early pregnancy loss is understudied, and as a result mental health disorders often go unnoticed and untreated,” she said.

Growing evidence shows that Black women in particular are at greater risk for chronic stressors that affect their overall health. “Black women are more likely to be exposed to trauma in their lifetime, such as physical and emotional abuse, neglect, and household instability, all of which predispose women to mental health disorders such as depression. Untreated maternal depression has an impact on future pregnancy outcomes such as increasing the risk of having a preterm delivery and/or delivering a low-birth-weight baby, outcomes where Black women are at disproportionately high risk in comparison to non-Black women,” Dr. Krishna said.

“This study found that the risk for depression after an early pregnancy loss is twice as high for Black women in comparison to non-Black women. The findings of this study further underscore the fact that Black women are at disproportionate high risk for poor maternal and pregnancy outcomes,” Dr. Krishna added.

“Structural racism is a major barrier to caring for the health of Black women. To care for the health of Black women we must overcome racial and ethnic disparities. Addressing disparities involves a multitiered approach, including identifying and addressing implicit bias in health care and improving access to health care for women of color,” she said.

“Additional research is needed in identifying at-risk women and mental health interventions that can improve the mental well-being of women after adverse pregnancy outcomes such as early pregnancy loss,” Dr. Krishna concluded.

The study was supported by the Society of Family Planning Research Fund. Lead author Dr. Shorter had no financial conflicts to disclose. Dr. Krishna had no financial conflicts to disclose.

SOURCE: Shorter JM et al. Obstet Gynecol. 2020 Dec 3. doi: 10.1097/AOG.0000000000004212.