Diversity in Medicine

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dr. Manning reported having no financial disclosures.

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

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

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

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

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

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

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

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

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

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

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

Dr. Manning reported having no financial disclosures.

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

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

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

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

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

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

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

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

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

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

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

Dr. Manning reported having no financial disclosures.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

An evolving transformation

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

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

How I define myself

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

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

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

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

An evolving transformation

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

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

How I define myself

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

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

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

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

An evolving transformation

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

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

How I define myself

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Hormone therapy and acne

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Hormone therapy and acne

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Hormone therapy and acne

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

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

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

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

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

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

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

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

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

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

The percentage of physicians in the United States who are Black has increased only 4% in the past 120 years, and the number of Black male doctors has not changed at all since 1940, according to a new study.

In 1900, 1.3% of physicians were Black. In 1940, 2.8% of physicians were Black, and by 2018 – when almost 13% of the population was Black – 5.4% of doctors were Black, reports Dan Ly, MD, PhD, MPP, an assistant professor of medicine at the University of California, Los Angeles, in a study published online April 19, 2021, in the Journal of General Internal Medicine.

The proportion of male Black physicians was 2.7% in 1940 and 2.6% in 2018.

Dr. Ly also found a significant wage gap. The median income earned by White doctors was $50,000 more than the median income of Black physicians in 2018. Dr. Ly based his findings on the U.S. Census Decennial Census long form, accessed via IPUMS, a free database funded by the National Institutes of Health and other organizations.

“If we care about the health of the population, particularly the health of Black patients, we should care about how small the proportion of our physicians who are Black is and the extremely slow progress we have made as a medical system in increasing that proportion,” Dr. Ly said in an interview.

Dr. Ly said he took on this research in part because previous studies have shown that Black patients are more likely to seek preventive care from Black doctors. Thus, increasing the numbers of Black physicians could narrow gaps in life expectancy between Whites and Blacks.

He also wanted to see whether progress had been made as a result of various medical organizations and the Association of American Medical Colleges undertaking initiatives to increase workforce diversity. There has been “very, very little” progress, he said.

Norma Poll-Hunter, PhD, the AAMC’s senior director of workforce diversity, said Dr. Ly’s report “was not surprising at all.”

The AAMC reported in 2014 that the number of Black men who apply to and matriculate into medical schools has been declining since 1978. That year, there were 1,410 Black male applicants and 542 Black enrollees. In 2014, there were 1,337 applicants and 515 enrollees.

Since 2014, Black male enrollment has increased slightly, rising from 2.4% in the 2014-2015 school year to 2.9% in the 2019-2020 year, the AAMC reported last year.

In addition, among other historically underrepresented minorities, “we really have seen very small progress” despite the increase in the number of medical schools, Dr. Poll-Hunter said in an interview.

The AAMC and the National Medical Association consider the lack of Black male applicants and matriculants to be a national crisis. The two groups started an alliance in 2020 aimed at finding ways to amplify and support Black men’s interest in medicine and the biomedical sciences and to “develop systems-based solutions to address exclusionary practices that create barriers for Black men and prevent them from having equitable opportunities to successfully enroll in medical school.”

Solutions include requiring medical school admissions committees and application screeners to undergo implicit bias awareness and mitigation training, adopting holistic admissions reviews, and incentivizing institutions of higher learning to partner with Black communities in urban and rural school systems to establish K-12 health sciences academies, said NMA President Leon McDougle, MD, MPH.

“There are the systems factors, and racism is a big one that we have to tackle,” said Dr. Poll-Hunter.

Diversity isn’t just about numbers, said Dr. McDougle, a professor of family medicine and associate dean for diversity and inclusion at Ohio State University, Columbus. “We know that medical school graduates who are African American or Black, Hispanic or Latinx, or American Indian or Alaskan Native are more likely to serve those communities as practicing physicians.

“The COVID-19 pandemic highlighted the urgent need for more African American or Black, Hispanic or Latinx, or American Indian or Alaskan Native physicians,” he said. “Inadequate access to culturally competent care has exacerbated existing health disparities, resulting in death and hospitalization rates up to three to four times the rates of European American or White people.”

Dr. Poll-Hunter also said that studies have shown that diversity in the classroom creates a more enriched learning environment and increases civic mindedness and cognitive complexity, “as well as helps us understand people who are different than ourselves.”

The diversity goal “is not about quotas, it’s about excellence,” she said. “We know that there’s talent that exists, and we want to make sure that everyone has an opportunity to be successful.”

Dr. Ly has disclosed no relevant financial relationships.

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

The percentage of physicians in the United States who are Black has increased only 4% in the past 120 years, and the number of Black male doctors has not changed at all since 1940, according to a new study.

In 1900, 1.3% of physicians were Black. In 1940, 2.8% of physicians were Black, and by 2018 – when almost 13% of the population was Black – 5.4% of doctors were Black, reports Dan Ly, MD, PhD, MPP, an assistant professor of medicine at the University of California, Los Angeles, in a study published online April 19, 2021, in the Journal of General Internal Medicine.

The proportion of male Black physicians was 2.7% in 1940 and 2.6% in 2018.

Dr. Ly also found a significant wage gap. The median income earned by White doctors was $50,000 more than the median income of Black physicians in 2018. Dr. Ly based his findings on the U.S. Census Decennial Census long form, accessed via IPUMS, a free database funded by the National Institutes of Health and other organizations.

“If we care about the health of the population, particularly the health of Black patients, we should care about how small the proportion of our physicians who are Black is and the extremely slow progress we have made as a medical system in increasing that proportion,” Dr. Ly said in an interview.

Dr. Ly said he took on this research in part because previous studies have shown that Black patients are more likely to seek preventive care from Black doctors. Thus, increasing the numbers of Black physicians could narrow gaps in life expectancy between Whites and Blacks.

He also wanted to see whether progress had been made as a result of various medical organizations and the Association of American Medical Colleges undertaking initiatives to increase workforce diversity. There has been “very, very little” progress, he said.

Norma Poll-Hunter, PhD, the AAMC’s senior director of workforce diversity, said Dr. Ly’s report “was not surprising at all.”

The AAMC reported in 2014 that the number of Black men who apply to and matriculate into medical schools has been declining since 1978. That year, there were 1,410 Black male applicants and 542 Black enrollees. In 2014, there were 1,337 applicants and 515 enrollees.

Since 2014, Black male enrollment has increased slightly, rising from 2.4% in the 2014-2015 school year to 2.9% in the 2019-2020 year, the AAMC reported last year.

In addition, among other historically underrepresented minorities, “we really have seen very small progress” despite the increase in the number of medical schools, Dr. Poll-Hunter said in an interview.

The AAMC and the National Medical Association consider the lack of Black male applicants and matriculants to be a national crisis. The two groups started an alliance in 2020 aimed at finding ways to amplify and support Black men’s interest in medicine and the biomedical sciences and to “develop systems-based solutions to address exclusionary practices that create barriers for Black men and prevent them from having equitable opportunities to successfully enroll in medical school.”

Solutions include requiring medical school admissions committees and application screeners to undergo implicit bias awareness and mitigation training, adopting holistic admissions reviews, and incentivizing institutions of higher learning to partner with Black communities in urban and rural school systems to establish K-12 health sciences academies, said NMA President Leon McDougle, MD, MPH.

“There are the systems factors, and racism is a big one that we have to tackle,” said Dr. Poll-Hunter.

Diversity isn’t just about numbers, said Dr. McDougle, a professor of family medicine and associate dean for diversity and inclusion at Ohio State University, Columbus. “We know that medical school graduates who are African American or Black, Hispanic or Latinx, or American Indian or Alaskan Native are more likely to serve those communities as practicing physicians.

“The COVID-19 pandemic highlighted the urgent need for more African American or Black, Hispanic or Latinx, or American Indian or Alaskan Native physicians,” he said. “Inadequate access to culturally competent care has exacerbated existing health disparities, resulting in death and hospitalization rates up to three to four times the rates of European American or White people.”

Dr. Poll-Hunter also said that studies have shown that diversity in the classroom creates a more enriched learning environment and increases civic mindedness and cognitive complexity, “as well as helps us understand people who are different than ourselves.”

The diversity goal “is not about quotas, it’s about excellence,” she said. “We know that there’s talent that exists, and we want to make sure that everyone has an opportunity to be successful.”

Dr. Ly has disclosed no relevant financial relationships.

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

The percentage of physicians in the United States who are Black has increased only 4% in the past 120 years, and the number of Black male doctors has not changed at all since 1940, according to a new study.

In 1900, 1.3% of physicians were Black. In 1940, 2.8% of physicians were Black, and by 2018 – when almost 13% of the population was Black – 5.4% of doctors were Black, reports Dan Ly, MD, PhD, MPP, an assistant professor of medicine at the University of California, Los Angeles, in a study published online April 19, 2021, in the Journal of General Internal Medicine.

The proportion of male Black physicians was 2.7% in 1940 and 2.6% in 2018.

Dr. Ly also found a significant wage gap. The median income earned by White doctors was $50,000 more than the median income of Black physicians in 2018. Dr. Ly based his findings on the U.S. Census Decennial Census long form, accessed via IPUMS, a free database funded by the National Institutes of Health and other organizations.

“If we care about the health of the population, particularly the health of Black patients, we should care about how small the proportion of our physicians who are Black is and the extremely slow progress we have made as a medical system in increasing that proportion,” Dr. Ly said in an interview.

Dr. Ly said he took on this research in part because previous studies have shown that Black patients are more likely to seek preventive care from Black doctors. Thus, increasing the numbers of Black physicians could narrow gaps in life expectancy between Whites and Blacks.

He also wanted to see whether progress had been made as a result of various medical organizations and the Association of American Medical Colleges undertaking initiatives to increase workforce diversity. There has been “very, very little” progress, he said.

Norma Poll-Hunter, PhD, the AAMC’s senior director of workforce diversity, said Dr. Ly’s report “was not surprising at all.”

The AAMC reported in 2014 that the number of Black men who apply to and matriculate into medical schools has been declining since 1978. That year, there were 1,410 Black male applicants and 542 Black enrollees. In 2014, there were 1,337 applicants and 515 enrollees.

Since 2014, Black male enrollment has increased slightly, rising from 2.4% in the 2014-2015 school year to 2.9% in the 2019-2020 year, the AAMC reported last year.

In addition, among other historically underrepresented minorities, “we really have seen very small progress” despite the increase in the number of medical schools, Dr. Poll-Hunter said in an interview.

The AAMC and the National Medical Association consider the lack of Black male applicants and matriculants to be a national crisis. The two groups started an alliance in 2020 aimed at finding ways to amplify and support Black men’s interest in medicine and the biomedical sciences and to “develop systems-based solutions to address exclusionary practices that create barriers for Black men and prevent them from having equitable opportunities to successfully enroll in medical school.”

Solutions include requiring medical school admissions committees and application screeners to undergo implicit bias awareness and mitigation training, adopting holistic admissions reviews, and incentivizing institutions of higher learning to partner with Black communities in urban and rural school systems to establish K-12 health sciences academies, said NMA President Leon McDougle, MD, MPH.

“There are the systems factors, and racism is a big one that we have to tackle,” said Dr. Poll-Hunter.

Diversity isn’t just about numbers, said Dr. McDougle, a professor of family medicine and associate dean for diversity and inclusion at Ohio State University, Columbus. “We know that medical school graduates who are African American or Black, Hispanic or Latinx, or American Indian or Alaskan Native are more likely to serve those communities as practicing physicians.

“The COVID-19 pandemic highlighted the urgent need for more African American or Black, Hispanic or Latinx, or American Indian or Alaskan Native physicians,” he said. “Inadequate access to culturally competent care has exacerbated existing health disparities, resulting in death and hospitalization rates up to three to four times the rates of European American or White people.”

Dr. Poll-Hunter also said that studies have shown that diversity in the classroom creates a more enriched learning environment and increases civic mindedness and cognitive complexity, “as well as helps us understand people who are different than ourselves.”

The diversity goal “is not about quotas, it’s about excellence,” she said. “We know that there’s talent that exists, and we want to make sure that everyone has an opportunity to be successful.”

Dr. Ly has disclosed no relevant financial relationships.

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

In the United States, the rate of mortality caused by severe maternal morbidity has improved over time, but failure to rescue is significantly more common among racial and ethnic minorities.

These failures are a “major contributing factor” to the disproportionately higher rate of maternal mortality among women of color, reported lead author Jean Guglielminotti, MD, PhD, of Columbia University, New York, and colleagues.

“Racial and ethnic disparities in severe maternal morbidity are a growing public health concern in the United States,” the investigators wrote in Obstetrics & Gynecology.

“The reported incidence of severe maternal morbidity is twofold to threefold higher among Black American women, compared with non-Hispanic White women; and although the difference is less pronounced, the incidence of severe maternal morbidity also is higher among Hispanic, Asian and Pacific Islander, and Native American women.”

The ensuant, disproportionate risk of maternal mortality may be further exacerbated by disparities in hospitals, according to the investigators. They noted that non-Hispanic White women tend to give birth in different hospitals than racial and ethnic minorities, and the hospitals serving people of color “are characterized by lower performance on maternal safety indicators.”

Even within hospitals that most often serve minorities, severe maternal morbidity is more common among women of color than women who are White, they added.

“However, the simple severe maternal morbidity rate is insufficient to assess hospital performance and should be complemented with the rate of failure to rescue,” wrote Dr. Guglielminotti and colleagues.
 

Measuring failure to rescue across racial and ethnic groups

According to the investigators, failure-to-rescue rate advances focus from complications themselves – which can occur when care is appropriate and may stem from patient characteristics – to a hospital’s response to such complications.

Using this metric, a 2016 study by Friedman and colleagues, which included data from 1998 to 2010, showed failure to rescue was more common among Hispanic and non-Hispanic Black women than white women.

The present study built upon these findings with data from almost 74 million delivery hospitalizations in the National Inpatient Sample (1999-2017). The population included 993,864 women with severe maternal morbidity, among whom 4,328 died.

Overall, the failure-to-rescue rate decreased over the course of the study from 13.2% in 1999-2000 to 4.5% in 2017 (P < .001).

Yet racial and ethnic inequities were apparent.

Compared with White women, non-Hispanic Black women had a significantly higher failure-to-rescue rate ratio (1.79; 95% CI, 1.77-1.81), as did Hispanic women (RR, 1.08; 95% CI, 1.06-1.09), women of other non-White racial/ethnic backgrounds (RR, 1.39; 95% CI, 1.37-1.41), and women documented without racial/ethnic designations (RR, 1.43; 95% CI, 1.42-1.45).

“Failure to rescue from severe maternal morbidity remains a major contributing factor to the excess maternal mortality in racial and ethnic minority women in the United States,” the investigators concluded. “This finding underscores the need to identify factors accounting for these disparities and develop hospital-based interventions to reduce excess maternal mortality in racial and ethnic minority women.”
 

Striving for progress through systemic change

According to Eve Espey, MD, MPH, of the University of New Mexico, Albuquerque, “this study adds to the literature demonstrating that structural racism and implicit bias have profound negative impacts,” which “has implications for action.”

“We must increase efforts to improve maternal safety, including the rollout of Alliance for Innovation on Maternal Health [AIM] bundles through statewide perinatal quality collaboratives,” Dr. Espey said. “AIM bundle implementation must focus on the context of health inequities related to racism and bias. Similarly, we must consider large scale public policy changes building on the Affordable Care Act, such as universal health coverage throughout the life span, [which] equitably increases access to quality health care for all.”

Constance Bohon, MD, of Sibley Memorial Hospital, Washington, offered a similar viewpoint, and suggested that further analyses could reveal the impacts of systemic changes, thereby guiding future interventions.

“It would be interesting to determine if declines in failure to rescue rates were greatest in states that implemented AIM safety bundles [in 2012] as compared with the states that did not,” Dr. Bohon said. “The same assessment could be made with a comparison between the states that did and those that did not approve the Medicaid expansion [in 2014]. Other beneficial data would be a comparison of the failure-to-rescue rates in hospitals that provide the same obstetrical level of care. Further studies need to be done in order to identify factors that have the greatest impact on the failure-to-rescue rate. Subsequently, proposals can be suggested for actions that can be taken to decrease the excess maternal mortality in racial and ethnic minorities.”
 

Comparing the U.S. with the rest of the world

In an accompanying editorial, Marian F. MacDorman, PhD, of the University of Maryland, College Park, and Eugene Declercq, PhD, of Boston University, put the findings in a global context.

They noted that, in the United States over the past 2 decades, the rate of maternal mortality has either remained flat or increased, depending on study methodology; however, the relative state of affairs between the United States and the rest of the world is more straightforward.

“What is clear is that U.S. maternal mortality did not decline from 2000 to 2018,” wrote Dr. MacDorman and Dr. Declercq. “This contrasts with World Health Organization data showing that maternal mortality declined by 38% worldwide and by 53% in Europe from 2000 to 2017. In fact, North America was the only world region to not show substantial declines in maternal mortality during the period, and U.S. maternal mortality rates are nearly twice those in Europe.”

Within the US, these shortcomings are felt most acutely among racial and ethnic minorities, they noted, as the present study suggests.

“The U.S. is still plagued by wide racial disparities, with similar or larger Black-White maternal mortality disparities in 2018 than existed in the 1940s,” they wrote. “Thus, any euphoria generated by the lack of increase in maternal mortality (if accurate) must be set in the context of worldwide improvements, in which the U.S. is an outlier with no improvement. The U.S. can and should do better!”

To this end, Dr. MacDorman and Dr. Declercq wrote, “additional training and vigilance among clinicians can help to avert these largely preventable deaths. In addition, applying this same rigor to preventing deaths that occur in the community before and after birth, combined with a focus on social determinants among women during the reproductive years, will be essential to lowering U.S. maternal mortality overall and eliminating longstanding racial inequities.”

The study received no external funding. The investigators reported no conflicts of interest.

In the United States, the rate of mortality caused by severe maternal morbidity has improved over time, but failure to rescue is significantly more common among racial and ethnic minorities.

These failures are a “major contributing factor” to the disproportionately higher rate of maternal mortality among women of color, reported lead author Jean Guglielminotti, MD, PhD, of Columbia University, New York, and colleagues.

“Racial and ethnic disparities in severe maternal morbidity are a growing public health concern in the United States,” the investigators wrote in Obstetrics & Gynecology.

“The reported incidence of severe maternal morbidity is twofold to threefold higher among Black American women, compared with non-Hispanic White women; and although the difference is less pronounced, the incidence of severe maternal morbidity also is higher among Hispanic, Asian and Pacific Islander, and Native American women.”

The ensuant, disproportionate risk of maternal mortality may be further exacerbated by disparities in hospitals, according to the investigators. They noted that non-Hispanic White women tend to give birth in different hospitals than racial and ethnic minorities, and the hospitals serving people of color “are characterized by lower performance on maternal safety indicators.”

Even within hospitals that most often serve minorities, severe maternal morbidity is more common among women of color than women who are White, they added.

“However, the simple severe maternal morbidity rate is insufficient to assess hospital performance and should be complemented with the rate of failure to rescue,” wrote Dr. Guglielminotti and colleagues.
 

Measuring failure to rescue across racial and ethnic groups

According to the investigators, failure-to-rescue rate advances focus from complications themselves – which can occur when care is appropriate and may stem from patient characteristics – to a hospital’s response to such complications.

Using this metric, a 2016 study by Friedman and colleagues, which included data from 1998 to 2010, showed failure to rescue was more common among Hispanic and non-Hispanic Black women than white women.

The present study built upon these findings with data from almost 74 million delivery hospitalizations in the National Inpatient Sample (1999-2017). The population included 993,864 women with severe maternal morbidity, among whom 4,328 died.

Overall, the failure-to-rescue rate decreased over the course of the study from 13.2% in 1999-2000 to 4.5% in 2017 (P < .001).

Yet racial and ethnic inequities were apparent.

Compared with White women, non-Hispanic Black women had a significantly higher failure-to-rescue rate ratio (1.79; 95% CI, 1.77-1.81), as did Hispanic women (RR, 1.08; 95% CI, 1.06-1.09), women of other non-White racial/ethnic backgrounds (RR, 1.39; 95% CI, 1.37-1.41), and women documented without racial/ethnic designations (RR, 1.43; 95% CI, 1.42-1.45).

“Failure to rescue from severe maternal morbidity remains a major contributing factor to the excess maternal mortality in racial and ethnic minority women in the United States,” the investigators concluded. “This finding underscores the need to identify factors accounting for these disparities and develop hospital-based interventions to reduce excess maternal mortality in racial and ethnic minority women.”
 

Striving for progress through systemic change

According to Eve Espey, MD, MPH, of the University of New Mexico, Albuquerque, “this study adds to the literature demonstrating that structural racism and implicit bias have profound negative impacts,” which “has implications for action.”

“We must increase efforts to improve maternal safety, including the rollout of Alliance for Innovation on Maternal Health [AIM] bundles through statewide perinatal quality collaboratives,” Dr. Espey said. “AIM bundle implementation must focus on the context of health inequities related to racism and bias. Similarly, we must consider large scale public policy changes building on the Affordable Care Act, such as universal health coverage throughout the life span, [which] equitably increases access to quality health care for all.”

Constance Bohon, MD, of Sibley Memorial Hospital, Washington, offered a similar viewpoint, and suggested that further analyses could reveal the impacts of systemic changes, thereby guiding future interventions.

“It would be interesting to determine if declines in failure to rescue rates were greatest in states that implemented AIM safety bundles [in 2012] as compared with the states that did not,” Dr. Bohon said. “The same assessment could be made with a comparison between the states that did and those that did not approve the Medicaid expansion [in 2014]. Other beneficial data would be a comparison of the failure-to-rescue rates in hospitals that provide the same obstetrical level of care. Further studies need to be done in order to identify factors that have the greatest impact on the failure-to-rescue rate. Subsequently, proposals can be suggested for actions that can be taken to decrease the excess maternal mortality in racial and ethnic minorities.”
 

Comparing the U.S. with the rest of the world

In an accompanying editorial, Marian F. MacDorman, PhD, of the University of Maryland, College Park, and Eugene Declercq, PhD, of Boston University, put the findings in a global context.

They noted that, in the United States over the past 2 decades, the rate of maternal mortality has either remained flat or increased, depending on study methodology; however, the relative state of affairs between the United States and the rest of the world is more straightforward.

“What is clear is that U.S. maternal mortality did not decline from 2000 to 2018,” wrote Dr. MacDorman and Dr. Declercq. “This contrasts with World Health Organization data showing that maternal mortality declined by 38% worldwide and by 53% in Europe from 2000 to 2017. In fact, North America was the only world region to not show substantial declines in maternal mortality during the period, and U.S. maternal mortality rates are nearly twice those in Europe.”

Within the US, these shortcomings are felt most acutely among racial and ethnic minorities, they noted, as the present study suggests.

“The U.S. is still plagued by wide racial disparities, with similar or larger Black-White maternal mortality disparities in 2018 than existed in the 1940s,” they wrote. “Thus, any euphoria generated by the lack of increase in maternal mortality (if accurate) must be set in the context of worldwide improvements, in which the U.S. is an outlier with no improvement. The U.S. can and should do better!”

To this end, Dr. MacDorman and Dr. Declercq wrote, “additional training and vigilance among clinicians can help to avert these largely preventable deaths. In addition, applying this same rigor to preventing deaths that occur in the community before and after birth, combined with a focus on social determinants among women during the reproductive years, will be essential to lowering U.S. maternal mortality overall and eliminating longstanding racial inequities.”

The study received no external funding. The investigators reported no conflicts of interest.

In the United States, the rate of mortality caused by severe maternal morbidity has improved over time, but failure to rescue is significantly more common among racial and ethnic minorities.

These failures are a “major contributing factor” to the disproportionately higher rate of maternal mortality among women of color, reported lead author Jean Guglielminotti, MD, PhD, of Columbia University, New York, and colleagues.

“Racial and ethnic disparities in severe maternal morbidity are a growing public health concern in the United States,” the investigators wrote in Obstetrics & Gynecology.

“The reported incidence of severe maternal morbidity is twofold to threefold higher among Black American women, compared with non-Hispanic White women; and although the difference is less pronounced, the incidence of severe maternal morbidity also is higher among Hispanic, Asian and Pacific Islander, and Native American women.”

The ensuant, disproportionate risk of maternal mortality may be further exacerbated by disparities in hospitals, according to the investigators. They noted that non-Hispanic White women tend to give birth in different hospitals than racial and ethnic minorities, and the hospitals serving people of color “are characterized by lower performance on maternal safety indicators.”

Even within hospitals that most often serve minorities, severe maternal morbidity is more common among women of color than women who are White, they added.

“However, the simple severe maternal morbidity rate is insufficient to assess hospital performance and should be complemented with the rate of failure to rescue,” wrote Dr. Guglielminotti and colleagues.
 

Measuring failure to rescue across racial and ethnic groups

According to the investigators, failure-to-rescue rate advances focus from complications themselves – which can occur when care is appropriate and may stem from patient characteristics – to a hospital’s response to such complications.

Using this metric, a 2016 study by Friedman and colleagues, which included data from 1998 to 2010, showed failure to rescue was more common among Hispanic and non-Hispanic Black women than white women.

The present study built upon these findings with data from almost 74 million delivery hospitalizations in the National Inpatient Sample (1999-2017). The population included 993,864 women with severe maternal morbidity, among whom 4,328 died.

Overall, the failure-to-rescue rate decreased over the course of the study from 13.2% in 1999-2000 to 4.5% in 2017 (P < .001).

Yet racial and ethnic inequities were apparent.

Compared with White women, non-Hispanic Black women had a significantly higher failure-to-rescue rate ratio (1.79; 95% CI, 1.77-1.81), as did Hispanic women (RR, 1.08; 95% CI, 1.06-1.09), women of other non-White racial/ethnic backgrounds (RR, 1.39; 95% CI, 1.37-1.41), and women documented without racial/ethnic designations (RR, 1.43; 95% CI, 1.42-1.45).

“Failure to rescue from severe maternal morbidity remains a major contributing factor to the excess maternal mortality in racial and ethnic minority women in the United States,” the investigators concluded. “This finding underscores the need to identify factors accounting for these disparities and develop hospital-based interventions to reduce excess maternal mortality in racial and ethnic minority women.”
 

Striving for progress through systemic change

According to Eve Espey, MD, MPH, of the University of New Mexico, Albuquerque, “this study adds to the literature demonstrating that structural racism and implicit bias have profound negative impacts,” which “has implications for action.”

“We must increase efforts to improve maternal safety, including the rollout of Alliance for Innovation on Maternal Health [AIM] bundles through statewide perinatal quality collaboratives,” Dr. Espey said. “AIM bundle implementation must focus on the context of health inequities related to racism and bias. Similarly, we must consider large scale public policy changes building on the Affordable Care Act, such as universal health coverage throughout the life span, [which] equitably increases access to quality health care for all.”

Constance Bohon, MD, of Sibley Memorial Hospital, Washington, offered a similar viewpoint, and suggested that further analyses could reveal the impacts of systemic changes, thereby guiding future interventions.

“It would be interesting to determine if declines in failure to rescue rates were greatest in states that implemented AIM safety bundles [in 2012] as compared with the states that did not,” Dr. Bohon said. “The same assessment could be made with a comparison between the states that did and those that did not approve the Medicaid expansion [in 2014]. Other beneficial data would be a comparison of the failure-to-rescue rates in hospitals that provide the same obstetrical level of care. Further studies need to be done in order to identify factors that have the greatest impact on the failure-to-rescue rate. Subsequently, proposals can be suggested for actions that can be taken to decrease the excess maternal mortality in racial and ethnic minorities.”
 

Comparing the U.S. with the rest of the world

In an accompanying editorial, Marian F. MacDorman, PhD, of the University of Maryland, College Park, and Eugene Declercq, PhD, of Boston University, put the findings in a global context.

They noted that, in the United States over the past 2 decades, the rate of maternal mortality has either remained flat or increased, depending on study methodology; however, the relative state of affairs between the United States and the rest of the world is more straightforward.

“What is clear is that U.S. maternal mortality did not decline from 2000 to 2018,” wrote Dr. MacDorman and Dr. Declercq. “This contrasts with World Health Organization data showing that maternal mortality declined by 38% worldwide and by 53% in Europe from 2000 to 2017. In fact, North America was the only world region to not show substantial declines in maternal mortality during the period, and U.S. maternal mortality rates are nearly twice those in Europe.”

Within the US, these shortcomings are felt most acutely among racial and ethnic minorities, they noted, as the present study suggests.

“The U.S. is still plagued by wide racial disparities, with similar or larger Black-White maternal mortality disparities in 2018 than existed in the 1940s,” they wrote. “Thus, any euphoria generated by the lack of increase in maternal mortality (if accurate) must be set in the context of worldwide improvements, in which the U.S. is an outlier with no improvement. The U.S. can and should do better!”

To this end, Dr. MacDorman and Dr. Declercq wrote, “additional training and vigilance among clinicians can help to avert these largely preventable deaths. In addition, applying this same rigor to preventing deaths that occur in the community before and after birth, combined with a focus on social determinants among women during the reproductive years, will be essential to lowering U.S. maternal mortality overall and eliminating longstanding racial inequities.”

The study received no external funding. The investigators reported no conflicts of interest.

A study of U.S. children across ethnic and racial groups found that Asians were least likely to receive therapy for ADHD, compared with White children – who had the highest odds of getting some kind of treatment over other groups.

Other studies have identified disparity problems in ADHD diagnosis, although results have varied on inequality metrics. Few studies have looked at Asians separately, according to the study’s lead author, Yu Shi, MD, MPH. “They were usually just classified as ‘other’ or as non-White,” Dr. Shi, a consultant with the Mayo Clinic’s division of pediatric anesthesia in Rochester, Minn., said in an interview.

Disparities might stem from cultural and socioeconomic factors, and the way in which clinicians interpret behavior and apply diagnostic criteria.

“Further understanding of how treatment patterns for ADHD may differ based on race, at the time of initial diagnosis and in the early stages of treatment, may help all children receive appropriate evidence-based care,” Dr. Shi and colleagues reported in JAMA Network Open.
 

Researchers develop large birth cohort

Dr. Shi and colleagues hypothesized that non-Hispanic White children had a greater chance of getting diagnosed and treated within the first year of diagnosis than that of other ethnic and racial cohorts. Using administrative claims data with socioeconomic status information from a national commercial insurance warehouse, they constructed a retrospective birth cohort of children born between Jan. 1, 2006, and Dec. 31, 2012. The children had continuous insurance coverage for at least 4 years, and represented non-Hispanic Whites, Blacks, Hispanics, and Asians. Self-reporting identified the race/ethnicity groups.

Investigators analyzed ADHD diagnosis and treatment data on 238,011 children between October 2019 and December 2020, using a multivariate Cox regression model to adjust for sex, region, and household income. Primary and secondary outcomes included ADHD diagnosis as defined by recent ICD codes, ADHD behavior, and medication therapies in the clinical setting after initial diagnosis, respectively.

Whites made up most of the cohort (72.7%), followed by Hispanics (9.8%), Asians (6.7%), and Blacks (6.2%). Nearly half the population was female (48.8%). During the follow-up period with these children, 11,401, or 4.8%, had received an ADHD diagnosis. Mean age of diagnosis was 6.5 years, and overall incidence of ADHD was 69 per 10,000 person years (95% confidence interval, 68-70).

Pediatricians were most likely to make an ADHD diagnosis, although the study cited other clinicians, such as psychiatrists, neurologists, psychologists, and family practice clinicians, as responsible for these decisions.

Children diagnosed with ADHD had more years of coverage in the data set, and were more likely to be White and male. The Southern census region had a higher representation of diagnoses (50.6%) than did the Northeast region (11.8%).
 

Asians at highest odds for no treatment

Taking a closer look at race and ethnicity, Whites had the highest cumulative incidence of ADHD (14.19%), versus Asian children, who had lowest incidence (6.08%). “The curves for Black and Hispanic children were similar in shape and slightly lower than that for White children,” reported the investigators.

White children had higher odds of receiving some kind of treatment, compared with the other groups.

Incidence of medication treatment was lower among Asians and Hispanics. In a striking finding, Asians were most likely to receive no treatment at all (odds ratio compared with White children, 0.54; 95% confidence interval, 0.42-0.70). “However, the percentage of Asian children receiving psychotherapy was not significantly lower than other groups, which is different than a 2013 study finding that Asian children with ADHD were less likely to use mental health services,” they noted.

Most of the patients received medication (32.4%) in the first year after diagnosis, whereas (19.4%) received behavioral therapy only. Nineteen percent had both. More than 29% of these cases had no claims associated with either treatment. Among school-aged children, 65.5% were prescribed medications, compared with just 14.4% who received therapy. Twenty percent had no treatment.

Diagnosis with another disorder often preceded ADHD diagnosis. Results varied among racial groups. White children were more likely than were Black children to be diagnosed with an anxiety or adjustment disorder. Relative to White children, Asians were more likely to be diagnosed with autism spectrum disorder, speech sound disorders, or unspecified neurodevelopmental disorders. Even after an ADHD diagnosis, clinicians were more likely to diagnose Asian children with autism.
 

Parents may influence treatment decisions

Parental views and preferences may explain some of the variations in diagnosis and treatment among the racial/ethnic groups.

“In order for a diagnosis of ADHD to happen, a parent has first to recognize a problem and bring a child for clinical evaluation,” said Dr. Shi. “A certain behavior could be viewed as normal or a problem depending on a person’s cultural or racial background.” It’s unclear whether clinicians played any role in diagnosis disparities, he added. Patients’ concerns about racism might also influence the desire to get treated in health care systems.

Overall, the findings underscore the presence of racial and ethnic disparities in ADHD diagnosis and treatment. Future research should explore the underlying mechanisms, Dr. Shi suggested. While he and his colleagues have no immediate plans to do another ADHD study, “we’re planning on research to understand disparities in surgery in children,” he said.

The authors cited numerous limitations with their study. Use of ICD codes to identify cases might not have represented true clinical diagnosis, since the data were collected for billing, not research purposes. Investigators drew participants from a commercial insurance database, which did not necessarily reflect all U.S. children. The results might not represent a large number of children covered by Medicaid, for example, noted Dr. Shi. “It is more difficult to work with Medicaid data because there’s no national-level Medicaid data for research. Only state-level data is available.”

Because of other data gaps, Dr. Shi and colleagues might have underestimated the number of children in therapy.
 

A need for ‘culturally sensitive care’

The findings “ultimately demonstrate the need for culturally sensitive care in the diagnosis and treatment of children and adolescents,” said Tiffani L. Bell, MD, a psychiatrist in Winston-Salem, N.C., who was not involved with the study. She specializes in child and adolescent psychiatry.

The exact cause for racial disparity in diagnosis and treatment of ADHD is unknown and likely multifaceted, she continued. “It may be due to differences in the way that disruptive behaviors are interrupted based on factors such as race. This study found that Asian parents often brought their children in for evaluation for reasons other than ADHD. Concerns surrounding the stigma of mental health treatment and racism also could contribute to the disparity in diagnosis and treatment,” she said.

Dr. Bell said she hopes to see future studies that address the impact of social determinants of health on mental illness and investigate underlying causes that contribute to disparities in treatment and diagnosis.

The Mayo Clinic supported the study but had no role in its design or research methods. The authors reported no conflicts of interest.

A study of U.S. children across ethnic and racial groups found that Asians were least likely to receive therapy for ADHD, compared with White children – who had the highest odds of getting some kind of treatment over other groups.

Other studies have identified disparity problems in ADHD diagnosis, although results have varied on inequality metrics. Few studies have looked at Asians separately, according to the study’s lead author, Yu Shi, MD, MPH. “They were usually just classified as ‘other’ or as non-White,” Dr. Shi, a consultant with the Mayo Clinic’s division of pediatric anesthesia in Rochester, Minn., said in an interview.

Disparities might stem from cultural and socioeconomic factors, and the way in which clinicians interpret behavior and apply diagnostic criteria.

“Further understanding of how treatment patterns for ADHD may differ based on race, at the time of initial diagnosis and in the early stages of treatment, may help all children receive appropriate evidence-based care,” Dr. Shi and colleagues reported in JAMA Network Open.
 

Researchers develop large birth cohort

Dr. Shi and colleagues hypothesized that non-Hispanic White children had a greater chance of getting diagnosed and treated within the first year of diagnosis than that of other ethnic and racial cohorts. Using administrative claims data with socioeconomic status information from a national commercial insurance warehouse, they constructed a retrospective birth cohort of children born between Jan. 1, 2006, and Dec. 31, 2012. The children had continuous insurance coverage for at least 4 years, and represented non-Hispanic Whites, Blacks, Hispanics, and Asians. Self-reporting identified the race/ethnicity groups.

Investigators analyzed ADHD diagnosis and treatment data on 238,011 children between October 2019 and December 2020, using a multivariate Cox regression model to adjust for sex, region, and household income. Primary and secondary outcomes included ADHD diagnosis as defined by recent ICD codes, ADHD behavior, and medication therapies in the clinical setting after initial diagnosis, respectively.

Whites made up most of the cohort (72.7%), followed by Hispanics (9.8%), Asians (6.7%), and Blacks (6.2%). Nearly half the population was female (48.8%). During the follow-up period with these children, 11,401, or 4.8%, had received an ADHD diagnosis. Mean age of diagnosis was 6.5 years, and overall incidence of ADHD was 69 per 10,000 person years (95% confidence interval, 68-70).

Pediatricians were most likely to make an ADHD diagnosis, although the study cited other clinicians, such as psychiatrists, neurologists, psychologists, and family practice clinicians, as responsible for these decisions.

Children diagnosed with ADHD had more years of coverage in the data set, and were more likely to be White and male. The Southern census region had a higher representation of diagnoses (50.6%) than did the Northeast region (11.8%).
 

Asians at highest odds for no treatment

Taking a closer look at race and ethnicity, Whites had the highest cumulative incidence of ADHD (14.19%), versus Asian children, who had lowest incidence (6.08%). “The curves for Black and Hispanic children were similar in shape and slightly lower than that for White children,” reported the investigators.

White children had higher odds of receiving some kind of treatment, compared with the other groups.

Incidence of medication treatment was lower among Asians and Hispanics. In a striking finding, Asians were most likely to receive no treatment at all (odds ratio compared with White children, 0.54; 95% confidence interval, 0.42-0.70). “However, the percentage of Asian children receiving psychotherapy was not significantly lower than other groups, which is different than a 2013 study finding that Asian children with ADHD were less likely to use mental health services,” they noted.

Most of the patients received medication (32.4%) in the first year after diagnosis, whereas (19.4%) received behavioral therapy only. Nineteen percent had both. More than 29% of these cases had no claims associated with either treatment. Among school-aged children, 65.5% were prescribed medications, compared with just 14.4% who received therapy. Twenty percent had no treatment.

Diagnosis with another disorder often preceded ADHD diagnosis. Results varied among racial groups. White children were more likely than were Black children to be diagnosed with an anxiety or adjustment disorder. Relative to White children, Asians were more likely to be diagnosed with autism spectrum disorder, speech sound disorders, or unspecified neurodevelopmental disorders. Even after an ADHD diagnosis, clinicians were more likely to diagnose Asian children with autism.
 

Parents may influence treatment decisions

Parental views and preferences may explain some of the variations in diagnosis and treatment among the racial/ethnic groups.

“In order for a diagnosis of ADHD to happen, a parent has first to recognize a problem and bring a child for clinical evaluation,” said Dr. Shi. “A certain behavior could be viewed as normal or a problem depending on a person’s cultural or racial background.” It’s unclear whether clinicians played any role in diagnosis disparities, he added. Patients’ concerns about racism might also influence the desire to get treated in health care systems.

Overall, the findings underscore the presence of racial and ethnic disparities in ADHD diagnosis and treatment. Future research should explore the underlying mechanisms, Dr. Shi suggested. While he and his colleagues have no immediate plans to do another ADHD study, “we’re planning on research to understand disparities in surgery in children,” he said.

The authors cited numerous limitations with their study. Use of ICD codes to identify cases might not have represented true clinical diagnosis, since the data were collected for billing, not research purposes. Investigators drew participants from a commercial insurance database, which did not necessarily reflect all U.S. children. The results might not represent a large number of children covered by Medicaid, for example, noted Dr. Shi. “It is more difficult to work with Medicaid data because there’s no national-level Medicaid data for research. Only state-level data is available.”

Because of other data gaps, Dr. Shi and colleagues might have underestimated the number of children in therapy.
 

A need for ‘culturally sensitive care’

The findings “ultimately demonstrate the need for culturally sensitive care in the diagnosis and treatment of children and adolescents,” said Tiffani L. Bell, MD, a psychiatrist in Winston-Salem, N.C., who was not involved with the study. She specializes in child and adolescent psychiatry.

The exact cause for racial disparity in diagnosis and treatment of ADHD is unknown and likely multifaceted, she continued. “It may be due to differences in the way that disruptive behaviors are interrupted based on factors such as race. This study found that Asian parents often brought their children in for evaluation for reasons other than ADHD. Concerns surrounding the stigma of mental health treatment and racism also could contribute to the disparity in diagnosis and treatment,” she said.

Dr. Bell said she hopes to see future studies that address the impact of social determinants of health on mental illness and investigate underlying causes that contribute to disparities in treatment and diagnosis.

The Mayo Clinic supported the study but had no role in its design or research methods. The authors reported no conflicts of interest.

A study of U.S. children across ethnic and racial groups found that Asians were least likely to receive therapy for ADHD, compared with White children – who had the highest odds of getting some kind of treatment over other groups.

Other studies have identified disparity problems in ADHD diagnosis, although results have varied on inequality metrics. Few studies have looked at Asians separately, according to the study’s lead author, Yu Shi, MD, MPH. “They were usually just classified as ‘other’ or as non-White,” Dr. Shi, a consultant with the Mayo Clinic’s division of pediatric anesthesia in Rochester, Minn., said in an interview.

Disparities might stem from cultural and socioeconomic factors, and the way in which clinicians interpret behavior and apply diagnostic criteria.

“Further understanding of how treatment patterns for ADHD may differ based on race, at the time of initial diagnosis and in the early stages of treatment, may help all children receive appropriate evidence-based care,” Dr. Shi and colleagues reported in JAMA Network Open.
 

Researchers develop large birth cohort

Dr. Shi and colleagues hypothesized that non-Hispanic White children had a greater chance of getting diagnosed and treated within the first year of diagnosis than that of other ethnic and racial cohorts. Using administrative claims data with socioeconomic status information from a national commercial insurance warehouse, they constructed a retrospective birth cohort of children born between Jan. 1, 2006, and Dec. 31, 2012. The children had continuous insurance coverage for at least 4 years, and represented non-Hispanic Whites, Blacks, Hispanics, and Asians. Self-reporting identified the race/ethnicity groups.

Investigators analyzed ADHD diagnosis and treatment data on 238,011 children between October 2019 and December 2020, using a multivariate Cox regression model to adjust for sex, region, and household income. Primary and secondary outcomes included ADHD diagnosis as defined by recent ICD codes, ADHD behavior, and medication therapies in the clinical setting after initial diagnosis, respectively.

Whites made up most of the cohort (72.7%), followed by Hispanics (9.8%), Asians (6.7%), and Blacks (6.2%). Nearly half the population was female (48.8%). During the follow-up period with these children, 11,401, or 4.8%, had received an ADHD diagnosis. Mean age of diagnosis was 6.5 years, and overall incidence of ADHD was 69 per 10,000 person years (95% confidence interval, 68-70).

Pediatricians were most likely to make an ADHD diagnosis, although the study cited other clinicians, such as psychiatrists, neurologists, psychologists, and family practice clinicians, as responsible for these decisions.

Children diagnosed with ADHD had more years of coverage in the data set, and were more likely to be White and male. The Southern census region had a higher representation of diagnoses (50.6%) than did the Northeast region (11.8%).
 

Asians at highest odds for no treatment

Taking a closer look at race and ethnicity, Whites had the highest cumulative incidence of ADHD (14.19%), versus Asian children, who had lowest incidence (6.08%). “The curves for Black and Hispanic children were similar in shape and slightly lower than that for White children,” reported the investigators.

White children had higher odds of receiving some kind of treatment, compared with the other groups.

Incidence of medication treatment was lower among Asians and Hispanics. In a striking finding, Asians were most likely to receive no treatment at all (odds ratio compared with White children, 0.54; 95% confidence interval, 0.42-0.70). “However, the percentage of Asian children receiving psychotherapy was not significantly lower than other groups, which is different than a 2013 study finding that Asian children with ADHD were less likely to use mental health services,” they noted.

Most of the patients received medication (32.4%) in the first year after diagnosis, whereas (19.4%) received behavioral therapy only. Nineteen percent had both. More than 29% of these cases had no claims associated with either treatment. Among school-aged children, 65.5% were prescribed medications, compared with just 14.4% who received therapy. Twenty percent had no treatment.

Diagnosis with another disorder often preceded ADHD diagnosis. Results varied among racial groups. White children were more likely than were Black children to be diagnosed with an anxiety or adjustment disorder. Relative to White children, Asians were more likely to be diagnosed with autism spectrum disorder, speech sound disorders, or unspecified neurodevelopmental disorders. Even after an ADHD diagnosis, clinicians were more likely to diagnose Asian children with autism.
 

Parents may influence treatment decisions

Parental views and preferences may explain some of the variations in diagnosis and treatment among the racial/ethnic groups.

“In order for a diagnosis of ADHD to happen, a parent has first to recognize a problem and bring a child for clinical evaluation,” said Dr. Shi. “A certain behavior could be viewed as normal or a problem depending on a person’s cultural or racial background.” It’s unclear whether clinicians played any role in diagnosis disparities, he added. Patients’ concerns about racism might also influence the desire to get treated in health care systems.

Overall, the findings underscore the presence of racial and ethnic disparities in ADHD diagnosis and treatment. Future research should explore the underlying mechanisms, Dr. Shi suggested. While he and his colleagues have no immediate plans to do another ADHD study, “we’re planning on research to understand disparities in surgery in children,” he said.

The authors cited numerous limitations with their study. Use of ICD codes to identify cases might not have represented true clinical diagnosis, since the data were collected for billing, not research purposes. Investigators drew participants from a commercial insurance database, which did not necessarily reflect all U.S. children. The results might not represent a large number of children covered by Medicaid, for example, noted Dr. Shi. “It is more difficult to work with Medicaid data because there’s no national-level Medicaid data for research. Only state-level data is available.”

Because of other data gaps, Dr. Shi and colleagues might have underestimated the number of children in therapy.
 

A need for ‘culturally sensitive care’

The findings “ultimately demonstrate the need for culturally sensitive care in the diagnosis and treatment of children and adolescents,” said Tiffani L. Bell, MD, a psychiatrist in Winston-Salem, N.C., who was not involved with the study. She specializes in child and adolescent psychiatry.

The exact cause for racial disparity in diagnosis and treatment of ADHD is unknown and likely multifaceted, she continued. “It may be due to differences in the way that disruptive behaviors are interrupted based on factors such as race. This study found that Asian parents often brought their children in for evaluation for reasons other than ADHD. Concerns surrounding the stigma of mental health treatment and racism also could contribute to the disparity in diagnosis and treatment,” she said.

Dr. Bell said she hopes to see future studies that address the impact of social determinants of health on mental illness and investigate underlying causes that contribute to disparities in treatment and diagnosis.

The Mayo Clinic supported the study but had no role in its design or research methods. The authors reported no conflicts of interest.

Hispanic diabetes patients are significantly less likely than Black or White patients to receive preventive guideline-based care soon after diagnosis, based on data from more than 7,000 individuals.

Racial and ethnic disparities in diabetes care remain a pervasive health problem, and minorities including non-Hispanic Blacks and Hispanics experience higher rates of complications, including retinopathy and neuropathy, compared with other groups, Felippe Ottoni Marcondes, MD, of Massachusetts General Hospital, Boston, and colleagues noted in a poster presented at the annual meeting of the Society for General Internal Medicine.

Data from previous studies have shown that diabetes patients who receive guideline-directed preventive care soon after diagnosis can reduce their risk of complications, they said.

To identify disparities in the provision of guideline-directed preventive care, the researchers analyzed data from 7,341 individuals who participated in the National Health Interview Survey from 2011 to 2017. They reviewed associations between race/ethnicity and visits to an eye specialist, a foot specialist, and checks of blood pressure and cholesterol in the past year among individuals diagnosed with diabetes within the past 5 years.

Overall, Hispanics had significantly lower rates of insurance coverage (75.9%), compared with non-Hispanic Whites (93.2%) and non-Hispanic Blacks (88.1%; P < .001).

Hispanics also were significantly less likely than Whites to have had a prior year eye exam (odds ratio, 0.80) and blood pressure check (OR, 0.45), after controlling for variables including age, sex, socioeconomic status, health insurance, general health status, U.S. region, marital status, body mass index, and various comorbidities.

Although insurance coverage mediated 42.8% of the total effect of race/ethnicity on annual eye specialist visits for Hispanics as compared with Whites, there was no significant effect for Blacks, compared with Whites.
 

COVID concerns impact diabetes disparities

“As the diabetes epidemic continues in the U.S., it is important to bring to the front of the diabetes care conversation racial/ethnic disparities that persisted or have been only partially addressed,” Dr. Marcondes said in an interview. “It is also important to emphasize that patients with diabetes are at higher risk for COVID-19 hospitalizations, complications, and death, and COVID-19 has disproportionately affected racial/ethnic minorities, so racial/ethnic minorities with diabetes have compounded risk of complications not only from diabetes but also from COVID-19.

“Importantly, our study highlights disparities in health care that are likely the product of systemic inequalities in access to care and insurance coverage at a moment when conversations about the race/racism and their health impact are fresh in the minds of public and health policy officials and the general public,” he emphasized.

“Unfortunately, I cannot say that I am surprised by our findings,” Dr. Marcondes said. “We expected to see some differences in the receipt of care for racial/ethnic minorities compared to white individuals for those recently diagnosed with diabetes, and that is exactly what our findings show.”

However, “what was perhaps intriguing is that disparities in the receipt of guideline-directed care were greater for Hispanic compared to White individuals than for Black compared to White individuals,” said Dr. Marcondes. “The causes of these differences are many. Hispanic individuals are less likely than White and Black persons to have insurance coverage.” Other unmeasured factors include language barriers that Hispanic individuals may face, as well as the bias and discrimination experienced by Hispanic and Black individuals alike.
 

Focus on equitable early intervention

“There is plenty of evidence in the medical literature that Black and Hispanic individuals with diabetes, as well as other minorities, have higher risk of complications of diabetes such as retinopathy, nephropathy, as well as cardiovascular risk factors such as high blood pressure and cholesterol,” Dr. Marcondes said. “Yet, complications in the time that immediately follows the diagnosis of diabetes are likely to be low.”

To reduce the risk of complications in the future, “physicians and health providers need to focus on providing equitable, guideline-directed treatment for their minority patients recently diagnosed with diabetes,” Dr. Marcondes emphasized. “Intervening early in the disease course will hopefully lead to a decrease in the rate of complications for racial/ethnic minorities. Clinicians, especially primary care physicians and providers, need to be aware that they are often the first encounter of many patients with the health care system. Effective communication and unbiased language on the part of clinicians will lead to stronger patient-physician relationships that foster opportunity to discuss disease prevention.

“Additional research is needed to evaluate the attitudes and biases of primary care providers and access the impact of patient navigation resources when treating minority patients with diabetes,” he concluded.

Digging Deeper into Disparities
“In diabetes, there are known racial and ethnic disparities such that minorities receive suboptimal screening and treatment, and have worse outcomes,” said Scott J. Pilla, MD, of The Johns Hopkins University School of Medicine, Baltimore, in an interview. 

“This study examines disparities in diabetes preventive measures in the U.S. using a national survey (NHIS) over the past decade. They took the important step of stratifying their analyses by health insurance and socioeconomic status which, in addition to race, may have a large impact,” said Dr. Pilla. However, “One critique of the poster is that it is unclear whether the researchers weighted their analyses to account for the nationally representative sampling of the NHIS survey,” he noted. 
Dr. Pilla said the finding that Hispanic patients had fewer diabetes preventive measures lines up with previous research in this area. 

“I was surprised that the disparities did not extend to black patients, who have been found to also receive suboptimal care compared to white patients in other studies,” he noted. 

The message for clinical practice: “Minorities with diabetes are at a higher risk of adverse diabetes outcomes and may need extra support and resources to achieve their evidence-based diabetes prevention,” Dr. Pilla said. 

“More research is needed to understand the root cause of racial and ethnic disparities in diabetes management to tease apart possible contributors including health insurance coverage, socioeconomic factors, cultural and community factors, and systemic racism. This will help inform targeted approaches to reducing disparities in diabetes care,” he emphasized.

The researchers had no relevant financial conflicts to disclose. Dr. Pilla had no financial conflicts to disclose. 

Hispanic diabetes patients are significantly less likely than Black or White patients to receive preventive guideline-based care soon after diagnosis, based on data from more than 7,000 individuals.

Racial and ethnic disparities in diabetes care remain a pervasive health problem, and minorities including non-Hispanic Blacks and Hispanics experience higher rates of complications, including retinopathy and neuropathy, compared with other groups, Felippe Ottoni Marcondes, MD, of Massachusetts General Hospital, Boston, and colleagues noted in a poster presented at the annual meeting of the Society for General Internal Medicine.

Data from previous studies have shown that diabetes patients who receive guideline-directed preventive care soon after diagnosis can reduce their risk of complications, they said.

To identify disparities in the provision of guideline-directed preventive care, the researchers analyzed data from 7,341 individuals who participated in the National Health Interview Survey from 2011 to 2017. They reviewed associations between race/ethnicity and visits to an eye specialist, a foot specialist, and checks of blood pressure and cholesterol in the past year among individuals diagnosed with diabetes within the past 5 years.

Overall, Hispanics had significantly lower rates of insurance coverage (75.9%), compared with non-Hispanic Whites (93.2%) and non-Hispanic Blacks (88.1%; P < .001).

Hispanics also were significantly less likely than Whites to have had a prior year eye exam (odds ratio, 0.80) and blood pressure check (OR, 0.45), after controlling for variables including age, sex, socioeconomic status, health insurance, general health status, U.S. region, marital status, body mass index, and various comorbidities.

Although insurance coverage mediated 42.8% of the total effect of race/ethnicity on annual eye specialist visits for Hispanics as compared with Whites, there was no significant effect for Blacks, compared with Whites.
 

COVID concerns impact diabetes disparities

“As the diabetes epidemic continues in the U.S., it is important to bring to the front of the diabetes care conversation racial/ethnic disparities that persisted or have been only partially addressed,” Dr. Marcondes said in an interview. “It is also important to emphasize that patients with diabetes are at higher risk for COVID-19 hospitalizations, complications, and death, and COVID-19 has disproportionately affected racial/ethnic minorities, so racial/ethnic minorities with diabetes have compounded risk of complications not only from diabetes but also from COVID-19.

“Importantly, our study highlights disparities in health care that are likely the product of systemic inequalities in access to care and insurance coverage at a moment when conversations about the race/racism and their health impact are fresh in the minds of public and health policy officials and the general public,” he emphasized.

“Unfortunately, I cannot say that I am surprised by our findings,” Dr. Marcondes said. “We expected to see some differences in the receipt of care for racial/ethnic minorities compared to white individuals for those recently diagnosed with diabetes, and that is exactly what our findings show.”

However, “what was perhaps intriguing is that disparities in the receipt of guideline-directed care were greater for Hispanic compared to White individuals than for Black compared to White individuals,” said Dr. Marcondes. “The causes of these differences are many. Hispanic individuals are less likely than White and Black persons to have insurance coverage.” Other unmeasured factors include language barriers that Hispanic individuals may face, as well as the bias and discrimination experienced by Hispanic and Black individuals alike.
 

Focus on equitable early intervention

“There is plenty of evidence in the medical literature that Black and Hispanic individuals with diabetes, as well as other minorities, have higher risk of complications of diabetes such as retinopathy, nephropathy, as well as cardiovascular risk factors such as high blood pressure and cholesterol,” Dr. Marcondes said. “Yet, complications in the time that immediately follows the diagnosis of diabetes are likely to be low.”

To reduce the risk of complications in the future, “physicians and health providers need to focus on providing equitable, guideline-directed treatment for their minority patients recently diagnosed with diabetes,” Dr. Marcondes emphasized. “Intervening early in the disease course will hopefully lead to a decrease in the rate of complications for racial/ethnic minorities. Clinicians, especially primary care physicians and providers, need to be aware that they are often the first encounter of many patients with the health care system. Effective communication and unbiased language on the part of clinicians will lead to stronger patient-physician relationships that foster opportunity to discuss disease prevention.

“Additional research is needed to evaluate the attitudes and biases of primary care providers and access the impact of patient navigation resources when treating minority patients with diabetes,” he concluded.

Digging Deeper into Disparities
“In diabetes, there are known racial and ethnic disparities such that minorities receive suboptimal screening and treatment, and have worse outcomes,” said Scott J. Pilla, MD, of The Johns Hopkins University School of Medicine, Baltimore, in an interview. 

“This study examines disparities in diabetes preventive measures in the U.S. using a national survey (NHIS) over the past decade. They took the important step of stratifying their analyses by health insurance and socioeconomic status which, in addition to race, may have a large impact,” said Dr. Pilla. However, “One critique of the poster is that it is unclear whether the researchers weighted their analyses to account for the nationally representative sampling of the NHIS survey,” he noted. 
Dr. Pilla said the finding that Hispanic patients had fewer diabetes preventive measures lines up with previous research in this area. 

“I was surprised that the disparities did not extend to black patients, who have been found to also receive suboptimal care compared to white patients in other studies,” he noted. 

The message for clinical practice: “Minorities with diabetes are at a higher risk of adverse diabetes outcomes and may need extra support and resources to achieve their evidence-based diabetes prevention,” Dr. Pilla said. 

“More research is needed to understand the root cause of racial and ethnic disparities in diabetes management to tease apart possible contributors including health insurance coverage, socioeconomic factors, cultural and community factors, and systemic racism. This will help inform targeted approaches to reducing disparities in diabetes care,” he emphasized.

The researchers had no relevant financial conflicts to disclose. Dr. Pilla had no financial conflicts to disclose. 

Hispanic diabetes patients are significantly less likely than Black or White patients to receive preventive guideline-based care soon after diagnosis, based on data from more than 7,000 individuals.

Racial and ethnic disparities in diabetes care remain a pervasive health problem, and minorities including non-Hispanic Blacks and Hispanics experience higher rates of complications, including retinopathy and neuropathy, compared with other groups, Felippe Ottoni Marcondes, MD, of Massachusetts General Hospital, Boston, and colleagues noted in a poster presented at the annual meeting of the Society for General Internal Medicine.

Data from previous studies have shown that diabetes patients who receive guideline-directed preventive care soon after diagnosis can reduce their risk of complications, they said.

To identify disparities in the provision of guideline-directed preventive care, the researchers analyzed data from 7,341 individuals who participated in the National Health Interview Survey from 2011 to 2017. They reviewed associations between race/ethnicity and visits to an eye specialist, a foot specialist, and checks of blood pressure and cholesterol in the past year among individuals diagnosed with diabetes within the past 5 years.

Overall, Hispanics had significantly lower rates of insurance coverage (75.9%), compared with non-Hispanic Whites (93.2%) and non-Hispanic Blacks (88.1%; P < .001).

Hispanics also were significantly less likely than Whites to have had a prior year eye exam (odds ratio, 0.80) and blood pressure check (OR, 0.45), after controlling for variables including age, sex, socioeconomic status, health insurance, general health status, U.S. region, marital status, body mass index, and various comorbidities.

Although insurance coverage mediated 42.8% of the total effect of race/ethnicity on annual eye specialist visits for Hispanics as compared with Whites, there was no significant effect for Blacks, compared with Whites.
 

COVID concerns impact diabetes disparities

“As the diabetes epidemic continues in the U.S., it is important to bring to the front of the diabetes care conversation racial/ethnic disparities that persisted or have been only partially addressed,” Dr. Marcondes said in an interview. “It is also important to emphasize that patients with diabetes are at higher risk for COVID-19 hospitalizations, complications, and death, and COVID-19 has disproportionately affected racial/ethnic minorities, so racial/ethnic minorities with diabetes have compounded risk of complications not only from diabetes but also from COVID-19.

“Importantly, our study highlights disparities in health care that are likely the product of systemic inequalities in access to care and insurance coverage at a moment when conversations about the race/racism and their health impact are fresh in the minds of public and health policy officials and the general public,” he emphasized.

“Unfortunately, I cannot say that I am surprised by our findings,” Dr. Marcondes said. “We expected to see some differences in the receipt of care for racial/ethnic minorities compared to white individuals for those recently diagnosed with diabetes, and that is exactly what our findings show.”

However, “what was perhaps intriguing is that disparities in the receipt of guideline-directed care were greater for Hispanic compared to White individuals than for Black compared to White individuals,” said Dr. Marcondes. “The causes of these differences are many. Hispanic individuals are less likely than White and Black persons to have insurance coverage.” Other unmeasured factors include language barriers that Hispanic individuals may face, as well as the bias and discrimination experienced by Hispanic and Black individuals alike.
 

Focus on equitable early intervention

“There is plenty of evidence in the medical literature that Black and Hispanic individuals with diabetes, as well as other minorities, have higher risk of complications of diabetes such as retinopathy, nephropathy, as well as cardiovascular risk factors such as high blood pressure and cholesterol,” Dr. Marcondes said. “Yet, complications in the time that immediately follows the diagnosis of diabetes are likely to be low.”

To reduce the risk of complications in the future, “physicians and health providers need to focus on providing equitable, guideline-directed treatment for their minority patients recently diagnosed with diabetes,” Dr. Marcondes emphasized. “Intervening early in the disease course will hopefully lead to a decrease in the rate of complications for racial/ethnic minorities. Clinicians, especially primary care physicians and providers, need to be aware that they are often the first encounter of many patients with the health care system. Effective communication and unbiased language on the part of clinicians will lead to stronger patient-physician relationships that foster opportunity to discuss disease prevention.

“Additional research is needed to evaluate the attitudes and biases of primary care providers and access the impact of patient navigation resources when treating minority patients with diabetes,” he concluded.

Digging Deeper into Disparities
“In diabetes, there are known racial and ethnic disparities such that minorities receive suboptimal screening and treatment, and have worse outcomes,” said Scott J. Pilla, MD, of The Johns Hopkins University School of Medicine, Baltimore, in an interview. 

“This study examines disparities in diabetes preventive measures in the U.S. using a national survey (NHIS) over the past decade. They took the important step of stratifying their analyses by health insurance and socioeconomic status which, in addition to race, may have a large impact,” said Dr. Pilla. However, “One critique of the poster is that it is unclear whether the researchers weighted their analyses to account for the nationally representative sampling of the NHIS survey,” he noted. 
Dr. Pilla said the finding that Hispanic patients had fewer diabetes preventive measures lines up with previous research in this area. 

“I was surprised that the disparities did not extend to black patients, who have been found to also receive suboptimal care compared to white patients in other studies,” he noted. 

The message for clinical practice: “Minorities with diabetes are at a higher risk of adverse diabetes outcomes and may need extra support and resources to achieve their evidence-based diabetes prevention,” Dr. Pilla said. 

“More research is needed to understand the root cause of racial and ethnic disparities in diabetes management to tease apart possible contributors including health insurance coverage, socioeconomic factors, cultural and community factors, and systemic racism. This will help inform targeted approaches to reducing disparities in diabetes care,” he emphasized.

The researchers had no relevant financial conflicts to disclose. Dr. Pilla had no financial conflicts to disclose.