Many studies have documented poorer patient-provider interactions among people of color compared to Whites, including lower-quality patient-provider communication, less involvement in decision making, and higher chances of perceived discrimination in healthcare encounters. In maternity care, where overuse of medical interventions such as cesarean delivery is a concern, women may try to exert agency by declining procedures. However, declining procedures may brand these women as uncooperative or non-compliant patients. The potential consequences of this are likely worse for women of color, who already expend more effort to manage their image during healthcare encounters in order to avoid stereotypes (e.g. the “angry Black woman”). Using a national sample of women who gave birth in U.S. hospitals in 2011–2012, we examined the relationship between declining procedures and discrimination during the childbirth hospitalization. We found that women who reported having declined care for themselves or their infant during the childbirth hospitalization were more likely to report “poor treatment” based on race and ethnicity, insurance status or having a difference of opinion with a healthcare provider. Moreover, the increase in odds of perceived discrimination due to a difference of opinion with a healthcare provider was significantly larger in magnitude for Black women compared to White women. These results suggest that in the context of childbirth care, women pay a penalty for exhibiting behavior that may be perceived as uncooperative, and this penalty may be greater for Black women.

<h3>Importance</h3><p>Burnout, a syndrome characterized by emotional exhaustion, depersonalization, and a decreased sense of efficacy, is common among resident physicians, and negative emotional states may increase the expression of prejudices, which are associated with racial disparities in health care. Whether racial bias varies by symptoms of burnout among resident physicians is unknown.</p><h3>Objective</h3><p>To assess the association between burnout and explicit and implicit racial biases toward black people in resident physicians.</p><h3>Design, Setting, and Participants</h3><p>This cohort study obtained data from surveys completed by first-year medical students and resident physicians in the United States as part of the Cognitive Habits and Growth Evaluation Study. Participants were followed up from enrollment in 2010 to 2011 through 2017. Participants completed questionnaires at year 4 of medical school as well as at the second and third years of residency. Only data from resident physicians who self-identified as belonging to a racial group other than black (n = 3392) were included in the analyses because of scarce evidence of racial bias in the care provided to black patients by black physicians. Resident physicians training in radiology or pathology were excluded because they provided less direct patient interaction.</p><h3>Main Outcomes and Measures</h3><p>Burnout symptoms were measured by 2 single-item measures from the Maslach Burnout Inventory. Explicit attitudes about white and black people were measured by a feeling thermometer (FT, from 0 to 100 points, ranging from very cold or unfavorable [lowest score] to very warm or favorable [highest score]; included in the second-year [R2] and third-year [R3] questionnaires). The R2 Questionnaire included a racial Implicit Association Test (IAT; range: –2 to 2).</p><h3>Results</h3><p>Among the 3392 nonblack resident physician respondents, 1693 (49.9%) were male, 1964 (57.9%) were younger than 30 years, and 2362 (69.6%) self-identified as belonging to the white race. In this cohort, 1529 of 3380 resident physicians (45.2%) had symptoms of burnout and 1394 of 3377 resident physicians (41.3%) had depression. From this group, 12 did not complete the burnout items and 15 did not complete the Patient-Reported Outcomes Measurement Information System (PROMIS) items. The mean (SD) FT score toward black people was 77.9 (21.0) and toward white people was 81.1 (20.1), and the mean (SD) racial IAT score was 0.4 (0.4). Burnout at the R2 Questionnaire time point was associated with greater explicit and implicit racial biases. In multivariable analyses adjusting for demographics, specialty, depression, and FT scores toward white people, resident physicians with burnout had greater explicit racial bias (difference in FT score, –2.40; 95% CI, –3.42 to –1.37;<i>P</i> &lt; .001) and implicit racial bias (difference in IAT score, 0.05; 95% CI, 0.02-0.08;<i>P</i> = .002). A dose-response association was found between change in depersonalization from R2 to R3 Questionnaire and R3 Questionnaire explicit bias (for each 1-point increase the difference in R3 FT score decreased, –0.73; 95% CI, –1.23 to –0.23;<i>P</i> = .004) and change in explicit bias.</p><h3>Conclusions and Relevance</h3><p>Among resident physicians, symptoms of burnout appeared to be associated with greater explicit and implicit racial biases; given the high prevalence of burnout and the negative implications of bias for medical care, symptoms of burnout may be factors in racial disparities in health care.</p>

PURPOSE: The purpose of this study was to examine the relationship between manifestations of racism in medical school and subsequent changes in graduating medical students' intentions to practice in underserved or minority communities, compared with their attitudes and intentions at matriculation. METHOD: The authors used repeated-measures data from a longitudinal study of 3,756 students at 49 U.S. medical schools that were collected from 2010 to 2014. They conducted generalized linear mixed models to estimate whether manifestations of racism in school curricula/policies, school culture/climate, or student attitudes/behaviors predicted first- to fourth-year changes in students' intentions to practice in underserved communities or primarily with minority populations. Analyses were stratified by students' practice intentions (no/undecided/yes) at matriculation. RESULTS: Students' more negative explicit racial attitudes were associated with decreased intention to practice with underserved or minority populations at graduation. Service learning experiences and a curriculum focused on improving minority health were associated with increased intention to practice in underserved communities. A curriculum focused on minority health/disparities, students' perceived skill at developing relationships with minority patients, the proportion of minority students at the school, and the perception of a tense interracial environment were all associated with increased intention to care for minority patients. CONCLUSIONS: This study provides evidence that racism manifested at multiple levels in medical schools was associated with graduating students' decisions to provide care in high-need communities. Strategies to identify and eliminate structural racism and its manifestations in medical school are needed.

The United States has seen unprecedented growth in the number of incarcerated women, most of whom are mothers with minor children. Major public health concerns relate to the reproductive health of women in prisons and jails and the well-being of their infants and young children. In the current article, we use a reproductive justice framework to examine the intersection of incarceration and maternal and child health. We review (a) current research on the reproductive health of incarcerated women, (b) characteristics and experiences of pregnant incarcerated women, (c) outcomes of infants and young children with incarcerated parents, (d) implications of research findings for policy and practice, and (e) the need for increased research, public education, and advocacy. We strongly recommend that correctional policies and practices be updated to address the common misconceptions and biases as well as the unique vulnerabilities and health needs of incarcerated women and their young children.

A growing body of evidence is beginning to highlight how mass incarceration shapes inequalities in population health. Non-Hispanic blacks are disproportionately affected by incarceration and criminal law enforcement, an enduring legacy of a racially-biased criminal justice system with broad health implications for black families and communities. Louisiana has consistently maintained one of the highest rates of black incarceration in the nation. Concurrently, large racial disparities in population health persist. We conducted a cross-sectional analysis of all births among non-Hispanic black women in Louisiana in 2014 to identify associations between parish-level (county equivalent) prevalence of jail incarceration within the black population and adverse birth outcomes (N = 23,954). We fit a log-Poisson model with generalized estimating equations to approximate the relative risk of preterm birth and low birth weight associated with an interquartile range increase in incarceration, controlling for confounders. In sensitivity analyses, we additionally adjusted for the parish-level index crime prevalence and analyzed regression models wherein white incarceration was used to predict the risk of adverse birth outcomes in order to quantify the degree to which mass incarceration may harm health above and beyond living in a high crime area. There was a significant 3% higher risk of preterm birth among black women associated with an interquartile range increase in the parish-level incarceration prevalence of black individuals, independent of other factors. Adjusting for the prevalence of index crimes did not substantively change the results of the models. Due to the positive significant associations between the prevalence of black individuals incarcerated in Louisiana jails and estimated risk of preterm birth, mass incarceration may be an underlying cause of the persistent inequities in reproductive health outcomes experienced by black women in Louisiana. Not only are there economic and social impacts stemming from mass incarceration, but there may also be implications for population health and health inequities, including the persistence of racial disparities in preterm birth and low birth weight.

Stereotype threat in secondary and undergraduate education can deteriorate Black students’ sense of well-being, belonging, and efficacy. Self-affirmation interventions have been shown to mitigate the negative psychological impact that stereotype threat has posed for Black students in these educational contexts. There is limited research that suggests that Black students in medical schools may also experience the negative impacts of stereotype threat. Until now, it has been unclear whether Black (vs. White) students experience a lower sense of belonging in medical school and whether they can benefit from self-affirmation interventions during medical training. With a longitudinal field experiment, we tested (a) whether Black (vs. White) medical students in the U.S. experience decrements in psychological well-being (i.e., fatigue, depression, anxiety), sense of belonging, and perceived residency competitiveness; and (b) the extent to which a self- affirmation intervention would ameliorate any observed disparities in these outcomes for Black students. With a sample of 234 Black and 182 White medical students across 50 schools in the U.S., we found that Black students tended to report more fatigue and less belonging than White students; however, the self-affirmation intervention did not significantly impact students’ fatigue, depression, anxiety, or belonging. Unexpectedly, Black students in the self-affirmation (vs. control) condition reported lower perceived competitiveness for residency. White students’ perceived competitiveness for residency was unaffected by the intervention.

Background: To fight racism and its potential influence on health, health care professionals must recognize, name, understand and talk about racism. These conversations are difficult, particularly when stakes feel high-in the workplace and in interracial groups. We convened a multidisciplinary, multi-racial group of professionals in two phases of this exploratory project to develop and pilot an intervention to promote effective dialogues on racism for first year medical students at the University of Minnesota Medical School. Methods: Informed by a Public Health Critical Race Praxis (PHCRP) methodology in Phase I, initial content was developed by a group of seven women primarily from racial and ethnic minority groups. In a later phase, they joined with five White (primarily male) colleagues to discuss racism and race. Participants met monthly for 12 months from Jan 2016-Dec 2016. All participants were recruited by study PI. An inductive approach was used to analyze meeting notes and post intervention reflections to describe lessons learned from the process of employing a PHCRP methodology to develop the aforementioned curriculum with a multidisciplinary and multi-racial group of professionals dedicated to advancing conversations on racial equity. Results: Participants from Phase I described the early meetings as “powerful,” allowing them to “bring their full selves” to a project that convened individuals who are often marginalized in their professional environments. In Phase II, which included White colleagues, the dynamics shifted: “…the voices from Phase I became quieter…”; “I had to put on my armor and fight in those later meetings…” Conclusions: The process of employing PHCRP in the development of an intervention about racism led to new insights on what it means to discuss racism among those marginalized and those with privilege. Conversations in each phase yielded new insights and strategies to advance a conversation about racism in health care.

Objectives: Although a range of factors shapes health and well-being, institutionalized racism (societal allocation of privilege based on race) plays an important role in generating inequities by race. The goal of this analysis was to review the contemporary peer-reviewed public health literature from 2002-2015 to determine whether the concept of institutionalized racism was named (ie, explicitly mentioned) and whether it was a core concept in the article. Methods: We used a systematic literature review methodology to find articles from the top 50 highest-impact journals in each of 6 categories (249 journals in total) that most closely represented the public health field, were published during 2002-2015, were US focused, were indexed in PubMed/MEDLINE and/or Ovid/MEDLINE, and mentioned terms relating to institutionalized racism in their titles or abstracts. We analyzed the content of these articles for the use of related terms and concepts. Results: We found only 25 articles that named institutionalized racism in the title or abstract among all articles published in the public health literature during 2002-2015 in the 50 highest-impact journals and 6 categories representing the public health field in the United States. Institutionalized racism was a core concept in 16 of the 25 articles. Conclusions: Although institutionalized racism is recognized as a fundamental cause of health inequities, it was not often explicitly named in the titles or abstracts of articles published in the public health literature during 2002-2015. Our results highlight the need to explicitly name institutionalized racism in articles in the public health literature and to make it a central concept in inequities research. More public health research on institutionalized racism could help efforts to overcome its substantial, longstanding effects on health and well-being.

OBJECTIVES/SPECIFIC AIMS: Calls to break the silence around the effects of racism on health are growing. Few researchers have examined the relationship between medical student characteristics and students’ comfort, motivation, and skill to discuss racism. This paper examines medical student characteristics associated with readiness to talk about racism among first-year medical students at the University of Minnesota. METHODS/STUDY POPULATION: In February 2017 prior to a lecture on racism and health, we invited first year medical students to participate in a web-based survey about their experiences and comfort discussing racism. We calculated descriptive statistics and measured differences by student race (White vs. Asian vs. Black/multiracial/other) and undergraduate major type (STEM vs. non-STEM) using χ 2 tests for variables with categorical responses and generalized linear regression models with pairwise comparisons (i.e., 2-sample t -tests) for variables with continuous responses. RESULTS/ANTICIPATED RESULTS: (n=107/163). The majority of students were male (53%); White (75%); and majored in STEM majors in college (85%). College major was not associated with race. Students’ responses to multiple items suggest that the vast majority perceived racial inequality as a major problem in the United States. Race was significantly associated with only 1 of these items. Specifically, 100% (16/16) of Black/multiracial/other students [under-represented minority (URM) students] reported “too little attention” is paid to race and racial issues, while only 53% of White students (42/79) and 55% of Asian students (6/11) chose this response. Students with non-STEM majors and students who identified as URM students reported talking about racism with friends more often than STEM majors and white students, respectively. In conversations about race at school, two-thirds of students were concerned that they might unintentionally offend others or be misunderstood. However, non-STEM majors and URM students were significantly less worried that they would unintentionally offend others in conversations about race at school than STEM majors and white students. Larger percentages of URM students (50%) than White students (25%) were afraid that others would not respect their views because of their race. White students were more afraid that they might that they would be called racist than URM students. DISCUSSION/SIGNIFICANCE OF IMPACT: Many students find it challenging to discuss race and racism in medical education settings. URM students and non-STEM majors reported greater frequency talking about racism with friends and appear to be less anxious in conversations about racism than White students and STEM majors respectively. Given non-STEM majors' greater psychological safety discussing racism, future research should explore whether non-STEM majors are better prepared and more motivated to address racial disparities in health and health care than STEM majors. Such research could have important implications for medical school admissions.

Objective: Patient–provider communication has been found to be less patient centred, on average, with patients who are members of stigmatized or minority groups. Obesity is a stigmatized condition, and thus, people with obesity may experience less patient-centred communication (PCC). The objective of this study was to assess the association between patient body mass index (BMI) and self-reported quality of PCC experienced over a 12-month period and whether that relationship differed for men and women. Methods: Data collected for the National Cancer Institute's Health Information National Trends Survey were analysed. Respondents who reported a BMI ≥ 18.5 kg/m2 and indicated having seen a healthcare provider outside of an emergency room in the last 12 months were included. PCC was measured using a validated six-item scale. Multivariate logistic regression was used to model the odds of reporting PCC greater than the sample median. Results: Compared with people with normal weight BMIs, no associations were found between overweight (odds ratio [OR] = 0.84, p = 0.17), class I & II obesity (OR = 0.94, p = 0.68) or class III obesity (OR = 0.86, p = 0.47) and PCC. There was a significant interaction (p = 0.015) such that for men, but not women, higher BMI was associated with less PCC. Conclusion: Unlike evidence that women experience more weight stigma, in the healthcare domain, men may be at elevated risk of experiencing communication influenced by weight stigma.

Due to a tagging error, two authors were incorrectly listed in indexing systems. Brook W. Cunningham should be B.A. Cunningham and Mark W. Yeazel should be M.W. Yeazel for indexing purposes.

<h3>Importance</h3><p>Burnout among physicians is common and has been associated with medical errors and lapses in professionalism. It is unknown whether rates for symptoms of burnout among resident physicians vary by clinical specialty and if individual factors measured during medical school relate to the risk of burnout and career choice regret during residency.</p><h3>Objective</h3><p>To explore factors associated with symptoms of burnout and career choice regret during residency.</p><h3>Design, Setting, and Participants</h3><p>Prospective cohort study of 4732 US resident physicians. First-year medical students were enrolled between October 2010 and January 2011 and completed the baseline questionnaire. Participants were invited to respond to 2 questionnaires; one during year 4 of medical school (January-March 2014) and the other during the second year of residency (spring of 2016). The last follow-up was on July 31, 2016.</p><h3>Exposures</h3><p>Clinical specialty, demographic characteristics, educational debt, US Medical Licensing Examination Step 1 score, and reported levels of anxiety, empathy, and social support during medical school.</p><h3>Main Outcomes and Measures</h3><p>Prevalence during second year of residency of reported symptoms of burnout measured by 2 single-item measures (adapted from the Maslach Burnout Inventory) and an additional item that evaluated career choice regret (defined as whether, if able to revisit career choice, the resident would choose to become a physician again).</p><h3>Results</h3><p>Among 4696 resident physicians, 3588 (76.4%) completed the questionnaire during the second year of residency (median age, 29 [interquartile range, 28.0-31.0] years in 2016; 1822 [50.9%] were women). Symptoms of burnout were reported by 1615 of 3574 resident physicians (45.2%; 95% CI, 43.6% to 46.8%). Career choice regret was reported by 502 of 3571 resident physicians (14.1%; 95% CI, 12.9% to 15.2%). In a multivariable analysis, training in urology, neurology, emergency medicine, and general surgery were associated with higher relative risks (RRs) of reported symptoms of burnout (range of RRs, 1.24 to 1.48) relative to training in internal medicine. Characteristics associated with higher risk of reported symptoms of burnout included female sex (RR, 1.17 [95% CI, 1.07 to 1.28]; risk difference [RD], 7.2% [95% CI, 3.1% to 11.3%]) and higher reported levels of anxiety during medical school (RR, 1.08 per 1-point increase [95% CI, 1.06 to 1.11]; RD, 1.8% per 1-point increase [95% CI, 1.6% to 2.0%]). A higher reported level of empathy during medical school was associated with a lower risk of reported symptoms of burnout during residency (RR, 0.99 per 1-point increase [95% CI, 0.99 to 0.99]; RD, −0.5% per 1-point increase [95% CI, −0.6% to −0.3%]). Reported symptoms of burnout (RR, 3.20 [95% CI, 2.58 to 3.82]; RD, 15.0% [95% CI, 12.8% to 17.3%]) and clinical specialty (range of RRs, 1.66 to 2.60) were both significantly associated with career choice regret.</p><h3>Conclusions and Relevance</h3><p>Among US resident physicians, symptoms of burnout and career choice regret were prevalent, but varied substantially by clinical specialty. Further research is needed to better understand these differences and to address these issues.</p>