Distrust Of Physicians Research Articles

Reflections from Chinese and Japanese Physicians on Medical Disputes

Physician–patient disputes are a major problem in healthcare. Physician–patient conflicts, workplace violence, and direct involvement in disputes have a significant negative impact on the well-being of physicians. China and Japan have similar cultures but differing healthcare systems. The present study aimed to examine and compare the experiences and perceptions of Chinese and Japanese physicians regarding medical disputes. Qualitative descriptive content analysis was performed for 18 cases from each country to assess the major issues involved in each case and their impact on the physicians. Common issues in medical disputes for both countries included monetary motives of patients and/or families, violence/threats from patients and/or families, the inability of patients and/or families to understand the risk of complications, and the uncertainties of medicine. The serious impact of medical disputes on the mental health and professionalism of physicians was also an issue shared by physicians of both countries. There were, however, differences in the magnitude and frequency of these issues between the two countries. Pre-existing distrust of physicians among patients and/or families was noted only by Chinese physicians, and insufficient information disclosure by physicians was noted only by Japanese physicians. In conclusion, there were similarities and differences between the two countries in the perceptions of physicians regarding medical disputes. Our analysis revealed differing healthcare situations due to cultural and institutional differences as well as universal problems intrinsic to medicine. Based on our results, we propose several key principles to improve the physician–patient relationship.

Associations of social determinants of health with avoidance of information, treatment receipt, and physician mistrust for women with breast cancer.

1507 Background: Social determinants of health (SDoH) are key factors contributing to breast cancer disparities but are difficult to measure. We surveyed a diverse population of women with breast cancer to identify SDoH and demographic measures associated with avoiding information, treatment receipt, and physician mistrust. Methods: During 2018-2020, we interviewed 297 women (60% White, 25% Black, 15% Hispanic) with a history of breast cancer treated at three academic institutions. We used multivariable regression to assess the associations of SDoH, demographics, and related factors (social support, discrimination in daily life and within healthcare, education, financial strain, faith, age, birth country, race and ethnicity, marital status) with three outcomes: (1) avoiding information about cancer, (2) lack of initiation of recommended treatments, and (3) physician mistrust. For each model, we included factors statistically significant (p<0.05) in unadjusted analyses. Results: Overall, 79 participants (26.6%) reported avoiding information about cancer. Age <40, discrimination (treated with less courtesy or as if dishonest), and financial strain (worry about medical bills, uninsured status) were all significantly associated with avoiding information (p<0.05 for all). In multivariable analyses, discrimination in daily life (OR 3.37, 95% CI 1.40-8.10 for being treated as if dishonest) and age (OR 3.36 for age <40 compared to >60) were associated with avoiding information. Twenty-two participants (7.4%) reported not initiating at least one recommended treatment. Discrimination in daily life and in healthcare were both significantly associated with treatment receipt, as was financial strain (all p<0.01). In multivariable analyses, discrimination (OR 3.51, 95% CI 1.05-11.76 for being treated as if dishonest) and worrying about medical bills (OR 3.53, 95% CI 1.40-8.93) were associated with lack of treatment initiation. Twelve participants (4.0%) reported not trusting physician’s judgements about medical care. Discrimination in daily life and in health care and insurance status were significantly associated with physician mistrust (both p<0.05). Multivariable analysis found that discrimination in both daily life and in health care (OR 5.95, 95% CI 1.40-25.3 for being treated with less courtesy in daily life, and OR 12.79, 95% CI 2.49-65.6 for reporting being treated as dishonest in health care setting) were associated with mistrust. Race and ethnicity were not significantly associated with any of the outcome measures in unadjusted or adjusted analyses (all p>0.05). Conclusions: SDoH measures and not race were associated with lack of engagement and trust within the health care system, with experiences of discrimination and financial strain associated with avoiding information, not initiating treatments, and physician mistrust.

Patient experience and pain outcomes among Black women with early-stage breast cancer after mastectomy.

e13751 Background: Racial pain disparities in breast cancer (BC) are well-described and persist despite prior trials to improve disparate pain outcomes. We previously found Black women (BW) reported more pain severity (PS) and interference with life (PI) after breast surgery compared to White women. Pain expression is multifactorial, and structural factors affect the ability to report and control pain. Perceived discrimination is associated with mistrust of medical providers, which affects clinical outcomes. Their impact on pain is understudied. We evaluated the association between discrimination, trust, and pain among BW with early-stage BC after mastectomy. Methods: BW with stage 0-III BC who had mastectomy ≤2 years of enrollment at academic and safety net hospitals in Houston, TX and Atlanta, GA, completed a demographic survey, Brief Pain Inventory (BPI), Discrimination in Medical Settings Scale (DMS), and Trust in Physician Scale (TPS). In BPI, worst, least, and average PS were reported from 0-10. PI from 0-10, pain treatments, and % relief were reported. DMS and TPS questions were on a 5-point Likert scale. We performed chart review to obtain baseline clinical data related to BC diagnosis, treatment and comorbidities. PI and DMS were scored as a mean of the total items of each survey. Mean Trust and Mistrust scores used means of TPS questions related to each category. Higher scores mean more PS, PI, discrimination, trust, or mistrust. We used ANOVA to examine associations between categorical variables and Pearson correlation coefficient for continuous variables. We performed univariate linear regression and multi-linear regression between specific variables and outcomes, accounting for collinearity. Results: Of the 77 BW surveyed, 66.2% received chemotherapy. 47.2% had a household income < $25,000, and 40.3% had private health insurance. PS, PI, DMS, and trust scores are shown (Table). Univariate analysis showed an association between DMS and mistrust (p=0.01), lower income and higher PS (p=0.01) and PI (p=0.04), and insurance status and PS (p=0.02) and PI (p=0.02). Associations between mistrust or DMS and pain were not statistically significant. A multivariate analysis with DMS as outcome showed an association with mistrust (p=0.04). Multivariate analysis also showed receipt of chemotherapy was associated with higher PS (p=0.02) and PI (p=0.03). Conclusions: BW have moderate pain up to 2 years following mastectomy. Participants reported low levels of discrimination and high trust. More discrimination was associated with more physician mistrust, but not PS or PI. Lower income and lack of private health insurance were associated with higher PS and PI. Future studies should address discrimination and trust in clinical settings and financial barriers to pain control. [Table: see text]

Trust in Physicians in the Context of HPV Vaccination of Children from the Perspective of Social Exchange Theory: A Representative Study of Polish Parents.

The vaccination of children against human papillomavirus (HPV) effectively prevents HPV infection and HPV-related cancers in women and men. However, HPV vaccination programs are met with vaccine hesitancy, which varies between countries. The coverage in Poland is low, although introducing nationally funded HPV vaccination for girls aged 12-13 in mid-2023 may increase it. The uptake of the HPV vaccine in adolescents is highly affected by parental decisions, which in turn can be influenced by interactions with the physician. The present representative study aimed to analyze the acceptance of the HPV vaccine among Polish parents (n = 360) and the level of trust in HPV vaccination in the pediatrician/general practitioner who takes care of their children aged 9-15 years. The data were gathered in September 2022 using computer-assisted telephone interviews. Most surveyed parents reported trusting their child's physician regarding vaccine recommendations (89.2%) and vaccinated their child with all or most of the vaccines recommended by a national vaccination guideline (94.7%). However, 13.3% declared themselves as moderate or strong vaccine opponents, a group characterized by high (83.4%) distrust in physicians. There was no difference in the awareness of HPV in groups varying in trusting the physicians, but parents who trusted them were more frequently aware of the HPV vaccine. Parental willingness to vaccinate their child against HPV was highly differentiated by the level of trust in the child's physician. The results highlight that trust in physicians is a critical factor shaping decisions for children's vaccination, stressing a continuous need to improve strategies to communicate with patients.

Case Report: A First Nation Man’s Journey with Severe Insulin Resistance Syndrome

James (a pseudonym) was born in the 1940s near Vancouver Island, British Columbia, to a Coast Salish family. His schooling was the imposed residential school system whereby Indigenous children were removed from their homes and communities and sent to schools in communities far away. His siblings attended various residential schools, so during his three years at such schools he saw them only in the summer time. His treatment during his schooling fostered a deep distrust of physicians and nurses. In addition he lost much of his native language and culture during this time. He graduated from Queen Elizabeth (High) School in North Surrey, British Columbia, where he was the only Indigenous student. James attended Vancouver Vocational School before returning to Vancouver Island to work as a band manager for his First Nation community. He married Mary (a pseudonym) and together they raised four children. Today he works as an Elder in Residence with post-secondary institutions on Vancouver Island.

Patient Adherence Following Knee Surgery: Evidence-Based Practices to Equip Patients for Success.

Patient adherence with postoperative wound care, activity restrictions, rehabilitation, medication, and follow-up protocols is paramount to achieving optimal outcomes following knee surgery. However, the ability to adhere to prescribed postoperative protocols is dependent on multiple factors both in and out of the patient's control. The goals of this review article are (1) to outline key factors contributing to patient nonadherence with treatment protocols following knee surgery and (2) to synthesize current management strategies and tools for optimizing patient adherence in order to facilitate efficient and effective implementation by orthopaedic health care teams. Patient adherence is commonly impacted by both modifiable and nonmodifiable factors, including health literacy, social determinants of health, patient fear/stigma associated with nonadherence, surgical indication (elective vs. traumatic), and distrust of physicians or the health care system. In addition, health care team factors, such as poor communication strategies or failure to follow internal protocols, and health system factors, such as prior authorization delays, staffing shortages, or complex record management systems, impact patient's ability to be adherent. Because the majority of factors found to impact patient adherence are nonmodifiable, it is paramount that health care teams adjust to better equip patients for success. For health care teams to successfully optimize patient adherence, focus should be paid to education strategies, individualized protocols that consider patient enablers and barriers to adherence, and consistent communication methodologies for both team and patient-facing communication.

Emergency Department Use in Black Individuals With Diabetes.

The prevalence of diabetes is higher in Black than in White individuals, and Blacks seek emergency department (ED) care for diabetes more often than Whites. This randomized controlled trial compared the efficacy of a novel intervention called the Diabetes Interprofessional Team to Enhance Adherence to Medical Care (DM I-TEAM) to usual medical care (UMC) to prevent return diabetes-related ED visits and hospitalizations over 12 months in 200 Black individuals with diabetes after an ED visit. The trial also identified baseline variables associated with return ED visits and hospitalizations. The DM I-TEAM provided diabetes education and behavioral activation services delivered by race-concordant research assistants, telehealth visits with a diabetes care and education specialist and primary care physicians, and clinical pharmacist recommendations. Participants had a mean age of 64.9 years, and 73.0% were women. There was no treatment group difference in return diabetes-related ED visits or hospitalizations over 12 months (DM I-TEAM n = 39 [45.3%] vs. UMC n = 37 [38.5%], χ2 = 0.864, P = 0.353). Baseline variables that were associated with return diabetes-related ED visits or hospitalizations were longer duration of diabetes, higher number of chronic health conditions, higher number of previous ED visits or hospitalizations, greater anticholinergic medication burden, lower satisfaction with primary care physicians, and lower trust in physicians (all P ≤0.05). Among Black individuals with diabetes, the DM I-TEAM interprofessional intervention was no better than UMC at preventing return diabetes-related ED visits or hospitalizations. High medical morbidity, greater anticholinergic medication burden, low satisfaction with primary care physicians, and physician mistrust were associated with diabetes-related ED visits or hospitalizations independent of treatment. Before clinical interventions such as the DM I-TEAM can be effective, reducing system-level barriers to health, improving physician-patient relationships and medication prescribing, and building community health care capacity will be necessary.

Racial disparities in utilization of palliative care among inpatients admitted for lung cancer.

e24166 Background: Multiple national database-based studies have shown that Black and Hispanic patients are less likely to receive palliative care options at end-of-life (EOL) inpatient care leading to higher costs and poorer quality of life. To the best of our knowledge, there is no reported data specifically considering lung and pleural malignancies. Methods: We analyzed hospitalizations across the United States in 2019 from the National Inpatient Sample dataset, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. We identified adult non-emergent hospitalizations with ‘malignant neoplasm of the lung and bronchus’ (including mesothelioma) listed as the principal reason for hospitalization using the International Classification of Diseases, 10th revision, clinical modification codes C34.0, C34.1, C34.2, C34.3, C34.8, C34.9, and their sub-branches. StataCorp Stata software was used to extract data and compute mortality and palliative care consult utilization among various demographic factors such as sex, age, race, and payer status. Results: Of 67,425 total hospitalizations, 9.4% resulted in mortality. Of these 6338 patients that died, 73.1% were White, 13% Black, 5.8% Hispanic, 3.9% Asians/Pacific Islanders, 0.6% Native Americans, and 3.3% were other races. Palliative care was consulted in 63% of the patients whose admission resulted in death. 64.9% of the White patients, 58.6% of the Black patients, 62.6% of Hispanic patients, 67.7% of Asians/Pacific Islanders, 60% Native Americans, and 59.6% of other races were offered palliative care prior to their death. The average age among the admissions which resulted in death was 69.03 years. Conclusions: While most admissions resulting in mortality were among the White population, there was still a clear discrepancy in the number of Black patients on whom palliative care was consulted. Possible reasons include poor healthcare literacy, physician mistrust, and cultural preferences. Clinicians should consider and suggest early palliative care consultation in the care of Black patients and other minority racial groups to improve the quality of EOL care.

(273) A Tight Tuck – More Than Meets the Eyes

Abstract Introduction Tucking is a common practice within the transwomen community. One study estimates that 70% of transwomen engage in this non-surgical gender affirming technique. It entails placement of the testes superiorly towards the inguinal canal and the penis inferiorly towards the rectum to conceal a male phenotype and create a female silhouette. By prolonged distortion of the normal anatomical lie of the penis and testes, several genitourinary complications should be expected to result including low sperm quality, genital pain, genitourinary tract infections, lower urinary tract symptoms, and testicular torsion. However, no formal review or survey has been conducted to better inform physicians on how to appropriately incorporate the practice of tucking into formation of a differential diagnoses. Objective To assess common genitourinary complications and complaints associated with the practice of tucking. Methods We performed a content analysis of posts on Reddit related to tucking and health complaints related to the practice. Reddit is an online forum with various sub-communities known as “subreddits” where anonymous users post and have discussions about a shared interest. In fact, there exist specific forums for the transgender community including r/asktrangender and r/MtF with 142,000 and 161,000 members respectively. A short survey was then created based on common themes of our analysis and posted to the 3 subreddits related to the transgender community with the most members. Results Content analysis first demonstrated distrust and displeasure in physicians’ understanding of genitourinary implications of tucking. Whether this reaction is well founded or not, it is true that there is little understanding within the medical community in this area with many physicians likely ignorant to the degree of anatomical distortion tucking entails. Analysis of common complaints revealed themes similar to those expected from review of what literature has been performed. We expect survey results to support our analysis. Conclusions Formal study is indicated of the genitourinary complications of tucking for physicians to adequately serve our transfemale patients. Disclosure No

Detect, predict, and prevent acute seizures and status epilepticus

Status epilepticus is one of the most frequent pediatric neurological emergencies. While etiology is often influencing the outcome, more easily modifiable risk factors of outcome include detection of prolonged convulsive seizures and status epilepticus and appropriately dosed and timely applied medication treatment. Unpredictability and delayed or incomplete treatment may at times lead to longer seizures, thereby affecting outcomes.Barriers in the care of acute seizures and status epilepticus include the identification of patients at greatest risk of convulsive status epilepticus, potential stigma, distrust, and uncertainties in acute seizure care, including caregivers, physicians, and patients. Furthermore, unpredictability, detection capability, and identification of acute seizures and status epilepticus, limitations in access to obtaining and maintaining appropriate treatment, and rescue treatment options pose challenges. Additionally, timing and dosing of treatment and related acute management algorithms, potential variations in care due to healthcare and physician culture and preference, and factors related to access, equity, diversity, and inclusion of care.We outline strategies for the identification of patients at risk of acute seizures and status epilepticus, improved status epilepticus detection and prediction, and acute closed-loop treatment and status epilepticus prevention. This paper was presented at the 8th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures held in September 2022.

Implementation of a Preventative Health Series at a Student-Run Free Clinic

The Rowan Community Health Clinic (RCHC), located in a small community in southern New Jersey, strives to promote positive healthcare experiences as part of its service in a largely underserved area. A significant number of RCHC’s patients are immigrants, lack primary care physicians, or have difficulty communicating with doctors. Many of them demonstrate limited health literacy, which has been associated with mismanagement of health conditions, increased costs, and distrust of physicians. Lack of opportunities for health education may contribute to decreased health literacy.
 To address this concern affecting its patient population, the RCHC implemented a monthly Preventative Health Series (PHS) with the goal of engaging the community in order to improve health literacy. A specific health topic was emphasized each month, such as Diabetes Awareness in November and Mental Health Awareness in December. Infographics providing information about the selected topic were shared throughout the month via social media. Furthermore, during the third week of the month, a doctor or medical student gave an interactive presentation intended to facilitate discussion about the topic among healthcare workers and community members. Due to the coronavirus disease of 2019 (COVID-19) pandemic, these discussions had to be conducted online. However, using an online platform also allowed us to reach a wider audience.

THE RELATIONSHIP BETWEEN HEALTHCARE STEREOTYPE THREAT AND ADVANCE CARE PLANNING AMONG HISPANIC PATIENTS

Abstract Experiencing ethnic/racial stereotype threat, the psychological experience of confronting stereotypes in the healthcare system, has been found to negatively impact healthcare outcomes (e.g. dissatisfaction with healthcare, poorer mental and physical health, higher physician distrust). Few studies have examined healthcare stereotype threat among Hispanics, and no study has tested how it might impact advance care planning outcomes among Hispanic hospitalized patients. This study aims to examine the relationship between healthcare stereotype threat and advance care planning activities among Hispanic hospitalized patients. We analyzed secondary data collected from a feasibility study of a palliative care educational intervention among 50 Spanish-speaking, Hispanic patients, over the age of 40, who were hospitalized in a large public hospital. Fifty percent had discussed future care if they were to become seriously ill, 18% had written instructions about their care (living will or advance directive), and 32% had a durable power of attorney (proxy) for healthcare. Results of logistic regressions revealed that greater healthcare stereotype threat scores were associated with lower odds of having discussed future care or medical treatment with others (OR=0.49, p=.03). However, healthcare stereotype threat scores were not associated with having provided written instructions about future medical care (OR=0.44; p=0.07), or with having a durable power of attorney for healthcare (OR=0.89; p=0.76). Future research should investigate ways to improve the cultural sensitivity in broaching discussions of future medical treatment among seriously ill patients. Additionally, more research and attention to policy implication are needed to reduce racial stereotype threat experienced in the healthcare system.

Twitter and Communicating Stigma about Medications to Treat Obesity

ABSTRACT In North America, stigma remains a significant barrier to treating obesity. Many candidates for medical weight management do not seek treatment, possibly related to anticipated and internalized stigma and weight bias. Pharmacologic treatment of obesity remains highly stigmatized, despite advances in drug development and medical weight management programs. People contemplating medical weight management are likely to see information about “diet pills” on social media sites, such as Twitter. However, Twitter has been found to contain false and stigmatizing information. This study examines a sample of 2170 Tweets to better understand the content through the lens of obesity stigma. Tweets were collected over a seven-day period containing general terms such as “diet pills,” “weight loss pills,” or “fat burner” using the Twitter advanced search option. The analysis revealed that almost 50% of Tweets containing “diet pills” contained stigmatizing language. The most common elements of stigma communication were taking personal blame for obesity and the perils associated with taking medications for weight loss. Further analysis revealed sub-themes such as profiting from social pressures to lose weight, distrust of physicians and the practice of obesity medicine, lack of efficacy of medications, and the use of social media to disseminate stigma. Most Tweets were from personal accounts followed by direct sales of weight loss supplements. The findings have potential implications for medically supervised weight management programs and may drive the need for more evidence-based social media messaging around obesity related healthcare.

Communication Skills (CS) training of physicians in China and its role in actual challenges of patient-physician relationship: a cross-sectional survey

BackgroundThe Chinese healthcare system is affected by frequent disputes between physicians and patients. Although recent reforms have contributed towards improving the patient-physician relationship, distrust in physicians is still high. Communication skills (CS) training of physicians holds the key to improving patient confidence and diffusing stressful situations. This survey reports on the status of CS training in medical education in China, and the experiences and attitudes of physicians towards CS training.MethodsA cross-sectional survey was conducted at medical institutions across China. A questionnaire developed for this study included the status of CS training, current aspects of patient-physician relationships, perceived own CS and patient-centeredness with Likert-scaled items from 1 (most negative) to 6 (most positive). Physicians’ attitude towards CS training was measured with the Communication Skills Attitude Scale (CSAS) and its subscales PAS (Positive Attitude Scale) and NAS (Negative Attitude Scale). Data were analyzed descriptively and for group differences between the hospital level and operating vs. non-operating physicians. Binary logistic regression analysis was done to find associations explaining the occurrence of verbal and physical attacks and the role of CS attitudes.ResultsOut of 1080 questionnaires, 772 physicians met inclusion criteria. A total of 466/772 participants (60.4%) had received at least one CS training during their career. The participants rated the current situation related to patient-physician relationship in China as highly stressful (mean = 4.52, SD = 1.26, 95% CI: 4.43–4.60), experiencing verbal attacks in the past three years once a year in 372/772 cases (48.2%) and physical attacks 111/772 times (14.4%). The mean PAS was 62.96 (SD = 7.63, 95% CI: 62.41–63.47). Being female was associated with increased risk of verbal attacks (OR = 1.51, 95% CI: 1.01–2.25) while working in a tertiary hospital and showing high levels of PAS decreased this risk (OR = 0.62, 95% CI: 0.43–0.89, and OR = 0.95, 95% CI: 0.93–0.98). Having received a previous CS training decreased the odds of physical attacks (OR = 0.54, 95% CI: 0.35–0.83).ConclusionsA majority of Chinese physicians showed a high positive attitude towards CS training, were trained in CS and would value further training. Our results highlight that CS training is likely to promote patient-centered communication and reduce attacks against physicians. Both of these effects are to improve the patient-physician-relationship in the long run. More CS training should be offered to Chinese physicians, especially at secondary- and primary-care hospitals, where such practices remain infrequent.

Integrating and Disseminating Pre-Exposure Prophylaxis (PrEP) Screening and Dispensing for Black Men Who Have Sex With Men in Atlanta, Georgia: Protocol for Community Pharmacies.

BackgroundBlack men who have sex with men (BMSM) suffer from alarmingly high rates of HIV in the United States. Pre-exposure prophylaxis (PrEP) can reduce the risk of HIV infection by 99% among men who have sex with men, yet profound racial disparities in the uptake of PrEP persist. Low PrEP uptake in BMSM is driven by poor access to PrEP, including inconvenient locations of PrEP-prescribing physicians, distrust of physicians, and stigma, which limit communication about PrEP and its side effects. Previous work indicates that offering HIV prevention services in pharmacies located in low-income, underserved neighborhoods is feasible and can reduce stigma because pharmacies offer a host of less stigmatized health services (eg, vaccinations). We present a protocol for a pharmacy PrEP model that seeks to address challenges and barriers to pharmacy-based PrEP specifically for BMSM.ObjectiveWe aim to develop a sustainable pharmacy PrEP delivery model for BMSM that can be implemented to increase PrEP access in low-income, underserved neighborhoods.MethodsThis study design is a pilot intervention to test a pharmacy PrEP delivery model among pharmacy staff and BMSM. We will examine the PrEP delivery model’s feasibility, acceptability, and safety and gather early evidence of its impact and cost with respect to PrEP uptake. A mixed-methods approach will be performed, including three study phases: (1) a completed formative phase with qualitative interviews from key stakeholders; (2) a completed transitional pilot phase to assess customer eligibility and willingness to receive PrEP in pharmacies during COVID-19; and (3) a planned pilot intervention phase which will test the delivery model in 2 Atlanta pharmacies in low-income, underserved neighborhoods.ResultsData from the formative phase showed strong support of pharmacy-based PrEP delivery among BMSM, pharmacists, and pharmacy staff. Important factors were identified to facilitate the implementation of PrEP screening and dissemination in pharmacies. During the transitional pilot phase, we identified 81 individuals who would have been eligible for the pilot phase.ConclusionsPharmacies have proven to be a feasible source for offering PrEP for White men who have sex with men but have failed to reach the most at-risk, vulnerable population (ie, BMSM). Increasing PrEP access and uptake will reduce HIV incidence and racial inequities in HIV. Translational studies are required to build further evidence and scale pharmacy-based PrEP services specifically for populations that are disconnected from HIV prevention resources.International Registered Report Identifier (IRRID)DERR1-10.2196/35590

Abstract 1122‐000062: Impact of COVID‐19 on Stroke Care in the United States and Potential Solutions

Introduction : The emergence of the COVID‐19 pandemic has negatively impacted medical care across the United States, especially so for rural communities. In this qualitative study, we investigated the barriers to the access of adequate treatment of ischemic stroke that have risen due to COVID‐19 in urban and rural regions of the United States of America. Methods : Using CDC data, we identified 16 regions, consisting of half urban and half rural regions, that had the highest stroke mortality rate and the highest incidence of COVID‐19 cases in the country. We compiled a list of neurointerventionalists practicing in these regions and designed a survey that was emailed to each neurointerventionalist. The survey investigated how stroke treatment in their hospital has been affected by the COVID‐19 pandemic; it additionally contained a request for a virtual interview to allow neurointerventionalists to discuss in greater detail the barriers to stroke treatment they are facing. Neurointerventionalists from hospitals across four urban regions and three rural regions filled out the survey and were then interviewed by Zoom or phone. Results : The survey and the interviews highlighted a number of barriers: hospitals in both urban and rural regions faced an unavailability of ICU beds during COVID surges. As COVID‐19 patients continued to occupy ICU beds, thrombectomy‐capable hospitals could not accept transfer stroke patients. These patients had to be diverted to other thrombectomy‐capable hospitals with vacant ICU beds, resulting in time lost before treatment. Stroke transfer posed more of a challenge in rural regions (as compared to urban communities) due to fewer rural‐area hospitals performing thrombectomy. Secondly, both urban and rural regions saw stroke patients delay their arrival to the hospital. In urban regions, stroke patients delayed their arrival by up to a week in some cases. Patients with milder stroke symptoms did not show up to the hospital for treatment at all, hoping the stroke would subside on its own. This pattern has been attributed to patients’ fear of contracting COVID‐19. In comparison, rural hospitals faced a smaller average delay of up to a few days, as many patients did not see the virus as a threat. The delay was attributed to some patients’ fear of the virus, fear of the procedure, or longstanding physician mistrust. Lastly, rural regions encountered an understaffing of nurses; a likely factor is the incidence of layoffs early in the pandemic, which lessened the time spent at a stroke patient’s bedside and impacted stroke outcome. Conclusions : Urban regions were quicker to adapt to the pandemic than rural regions. They had a greater number of available staff and vacant ICU beds to be able to treat patients with minimal interference. Urban regions could still consider having nearby hospitals communicate with each other so that they can share the burden of care and prevent a single hospital from becoming overwhelmed. Rural regions could especially focus on hiring travel nurses in cases of understaffing, increasing the number of thrombectomy performing centers, and pushing the education of stroke.

The Care Children Deserve

The Care Children Deserve

Health Control Beliefs and Attitude Toward Treatment in Psychiatric and Non-Psychiatric Clinical Samples.

Although there is accumulating evidence on the potential influencing factors of medication adherence, the knowledge about patients' attitudes and beliefs toward treatment is only partly utilized in adherence-improving strategies. Several internal and external factors determining adherence have been described regarding many chronic somatic diseases but in recent research, insight on psychiatric patients has been exclusively lacking. As a result, there is a scarcity of effective adherence-improving interventions. Identification of any specific differences or similarities between the attitudes toward treatment of psychiatric and non-psychiatric patients would help to support adherent behavior.We recruited 189 participants from four departments of general psychiatry (GEN PSYCH, n = 106), addictology (ADDICT, n = 42) and somatic diseases (NON PSYCH, n = 41). The Patient's Health Belief Questionnaire on Psychiatric Treatment (PHBQPT) was performed to assess the patients' attitude toward drug treatment, perceived health locus of control, and psychological reactance.The most robust difference of the PHBQT scores occurred between the GEN PSYCH and ADDICT subgroups. ADDICT patients scored significantly higher on the internal and external health locus of control and on the Psychological Reactance subscale as well. While GEN PSYCH subjects provided higher scores on the Positive Aspect of Medication compared to ADDICT persons. Interestingly, the only difference between the GEN PSYCH and NON-PSYCH groups was the more pronounced mistrust in physicians in the case of psychiatric patients.Our data suggest that mistrust toward medication does not differ in psychiatric and non-psychiatric samples, while the acceptance of the doctor's competency may be stronger in the non-psychiatric sample. The analysis of these factors provides information which could help us better understand this important issue and to develop more efficient interventions for improving adherence.

The Silent Majority: A Mixed Methods Analysis on the Perspectives of Women Who Forgo Post Mastectomy Breast Reconstruction

PURPOSE: Post mastectomy breast reconstruction (PMBR) is an important component of breast cancer care that is associated with improved psychosocial well-being and survival.1–3 The Women’s Heath and Cancer Rights Act of 1998 mandated insurance coverage for reconstruction; however, rates of PMBR remain stagnant at approximately 40%.4 There is a paucity of research on women who forgo reconstruction despite representing the majority of the post mastectomy patient population.5 This study addresses that gap by investigating barriers in the preoperative pathway faced by patients who forgo PMBR. METHODS: A mixed-methods study was performed using in-depth qualitative interviews and the BREAST-Q questionnaire. The study population consisted of women who received a referral to plastic surgery but choose to forgo PMBR. Women were stratified into 2 groups based on utilization of the referral to plastic surgery or lack thereof. Separate interview guides were developed for both groups, and interviews were conducted until data saturation was reached. Interviews were coded and analyzed using iterative methodologies (eg, open, axial, and selective coding) under the grounded-theory framework. The qualitative interview data and quantitative BREAST-Q data were analyzed using concurrent triangulation methodology. Reliability and validation checks included member-checking and inter-rater reliability using Cohen’s kappa statistic (mean kappa = 0.99). RESULTS: Interviews with 8 patients who forwent PMBR revealed: (1) lack of trust in both breast and plastic surgeons was salient; (2) reliance on self-developed support networks and resources; (3) association between lower post mastectomy BREAST-Q scores and decreased utilization of referral to plastic surgery; and (4) dissonance between numerical BREAST-Q scores for psychosocial well-being and reported satisfaction. CONCLUSIONS: These findings lay the conceptual groundwork acknowledging that nonlegislative and nonfinancial barriers, such as physician distrust and lack of resources and patient-tailored information, contributes to underutilization of PMBR in certain populations. Use of qualitative methodology uncovered deficits in the current pathway to reconstruction faced by the silent majority of women who forgo PMBR including lack of trust in physicians, resources, and counseling. These findings suggest unmet needs of patients considering PMBR which necessitates efforts to address these deficits and increase quality of life and satisfaction after mastectomy by empowering vulnerable patient groups. REFERENCES: 1. Ng SK, Hare RM, Kuang RJ, et al. Breast reconstruction post mastectomy: patient satisfaction and decision making. Ann Plast Surg. 2016;76:640–644. 2. Lee CN, Deal AM, Huh R, et al. Quality of patient decisions about breast reconstruction after mastectomy. JAMA Surg. 2017;152:741–748. 3. Sheehan J, Sherman KA, Lam T, et al. Association of information satisfaction, psychological distress and monitoring coping style with post-decision regret following breast reconstruction. Psychooncology. 2007;16:342–351. 4. American Cancer Society. What are the key statistics about breast cancer? Available at http://www.cancer.org/cancer/breastcancer/detailedguide/breast-cancer-key-statistics. 5. Alderman AK, Hawley ST, Janz NK, et al. Racial and ethnic disparities in the use of postmastectomy breast reconstruction: results from a population-based study. J Clin Oncol. 2009;27:5325–5330.

Applying lessons from vaccination hesitancy to address birth dose Vitamin K refusal: Where has the trust gone?

Refusal of intramuscular Vitamin K at birth is an emerging public health issue resulting in increased rates of intracranial bleeding. Parents who refuse this intervention bear epidemiologic resemblance to vaccine-refusing parents, are geographically clustered and share a mistrust of public health interventions. We review the prevalence of Vitamin K refusal and discuss individual and societal recommendations that may reduce Vitamin K refusal, adapted from vaccine hesitancy literature. We note the prevalence of misinformation on social media as a contributor to refusal and explore how changes in healthcare practices may influence growing physician mistrust. We propose solutions to the issue including state-based mandates and a pervasive social media strategy to combat misinformation as a contributor to Vitamin K refusal.