Physician Bias Research Articles

Physician Bias in Clinic practice

Physician Bias in Clinic practice

Exploring primary care physician biases in adolescent contraceptive counseling

Objective(s)While previous literature has shown clinician bias in adult contraceptive counseling, less is known on the biases clinicians may exhibit when counseling adolescents about contraception. Our study aimed to describe long-acting reversible contraception (LARC) counseling and prescribing practices of adolescent-serving clinicians. Study designThis study used a cross-sectional discrete choice experiment mixed methods design. We sent a survey containing vignettes and items pertaining to demographics and beliefs to a convenience sample of adolescent-serving clinicians across the United States. ResultsOf 296 clinicians, 80% were in pediatrics, and had geographic, practice setting, gender, and racial diversity. Most clinicians reported being up-to-date with current literature regarding contraception. Sixty-eight percent of respondent’s practices administer contraceptive injections, but only 17% place intrauterine devices (IUDs). Of those who do insert IUDs, nearly half inserted five or fewer within the last year. Patients’ younger age and Hispanic ethnicity were associated with lower odds, and history of pregnancy was associated with higher odds, of clinicians’ recommending LARC. Across all vignettes, the top five reasons clinicians chose their first-choice method for the patient were adherence or compliance, efficacy, side effects, patient age, and reversibility. Conclusion(s)Clinicians often recommend contraceptives based on adherence, efficacy, and age, and we found younger age, minoritized race or ethnicity, and history of pregnancy were all associated with LARC recommendations, indicating potential biases against teen parents and assumptions about adolescents’ priorities. This may impede the provision of patient-centered contraceptive counseling for adolescents, and highlights the need for improved education and practice changes post-Dobbs. ImplicationsWe found that clinicians demonstrated several biases in how they provide contraceptive recommendations to adolescent patients. These biases were often associated with their personal beliefs and experiences. Our findings can guide the development of future interventions aimed at improving adolescent reproductive health counseling and care delivery in primary care settings.

The mode of delivery after operative fixation of pelvic ring fractures-a retrospective observational study.

The purpose of this study is to investigate whether retained hardware after surgical treatment for a pelvic fracture prior to pregnancy affects the choice of delivery method. The study aims to provide insights into the rates of vaginal delivery and caesarean sections, understanding whether the mode of delivery was influenced by patient preference or the recommendations of obstetricians or surgeons, and examining the rate of complications during delivery and postpartum. All women of childbearing age who underwent surgical fixation for a pelvic ring fracture between 1994 and 2021 were identified. A questionnaire was sent about their possible pregnancies and deliveries. Of the included patients, surgical data were collected and the fracture patterns were retrospectively classified. Follow-up was a minimum of 36months. A total of 168 women with a pelvic fracture were identified, of whom 13 had a pregnancy after surgical stabilization. Eleven women had combined anterior and posterior fracture patterns and two had isolated sacral fractures. Four women underwent combined anterior and posterior fixation, the others either anterior or posterior fixation. Seven women had a total of 11 vaginal deliveries, and 6 women had 6 caesarean sections. The decision for vaginal delivery was often the wish of the mother (n = 4, 57%) while the decision to opt for caesarean section was made by the surgeon or obstetrician (n = 5, 83%). One woman in the vaginal delivery group suffered a postpartum complication possibly related to her retained pelvic hardware. Women with retained hardware after pelvic ring fixation can have successful vaginal deliveries. Complications during labor or postpartum are rare. The rate of primary caesarean sections is high (46%) and is probably influenced by physician bias. Future research should focus on tools that can predict labor outcomes in this specific population, and larger multicenter studies are needed. Level III.

Real-World 1-Year Outcomes of Treatment-Intensive Neovascular Age-Related Macular Degeneration Switched to Faricimab

PurposeTo report one-year anatomical and functional real-world outcomes of treatment intensive neovascular age related macular degeneration (nAMD) patients switched to faricimab DesignRetrospective multi-centre cohort study SubjectsConsecutive nAMD patients on 4-weekly treatment interval with either ranibizumab or aflibercept 2mg in the last three visits within a treat and extend protocol (high treatment burden) prior to switch to faricimab at Moorfields Eye Hospital between 5/9/2022- 5/12/2022. MethodsTotal number of nAMD patients switched to faricimab were identified from electronic medical records and those who met criteria of high treatment burden were included. Data collected included pre and post-switch visual acuity (VA), treatment intervals, length of follow-up, baseline macular morphology, changes in central subfield thickness (CST), macular fluid status and adverse events. Main outcome measuresVA, CST, presence of intraretinal fluid (IRF), subretinal fluid (SRF) and injection intervals over one-year following switch to faricimab. ResultsA total of 130/ 286 (45.5%) eyes met inclusion criteria of being switched due to high treatment burden and 117 were included in analysis. Prior to switch to faricimab, these eyes received mean total number of injections of 33.4±19.6 over mean of 51.3±34.9 months. Mean number of injections in 12 months preceding switch was 10.1±1.6 and mean interval of the preceding three injections was 4.2±0.3 weeks. Mean VA, CST and percentage of patients with dry macula prior to switch were 66.0±11.9 ETDRS letters, 259.6±76.0μm and 18.3% respectively. Following switch, there was no statistical difference in mean VA after each visit and at 12 months. Mean CST statistically significantly reduced following the 3rd faricimab injection and at 12 months by 20.0μm (p=0.035) and 22.1μm (p=0.041) respectively. Mean treatment intervals increased to 6.9±2.3 weeks (p<0.005) at 12 months with 42.9% and 11.4% of patients being on ≥8 weekly and ≥12 weekly treatment intervals respectively. ConclusionAt 12 months, patients with nAMD with previous record of high treatment burden when switched to faricimab maintained visual acuities and improved anatomical outcomes on extended treatment intervals. Physician bias is inherent in these types of observational studies so a prospective randomised controlled trial is recommended to validate these findings.

Evaluating Stigmatization Toward Mental Illnesses Among Resident Physicians.

Background Individuals with mental illness are stigmatized by peers in societal, workplace, and healthcare settings. The stigmatization individuals experience from healthcare providers is well documented and pervasive, often being a detriment to the quality of healthcare these individuals receive. Objective Recognizing and addressing stigmatization towardindividuals with mental illnesses is imperative during residency training inGraduate Medical Education (GME) programs and throughout professional practice. We hope that this cross-sectional study will cultivate mindfulness and improve the healthcare outcomes of stigmatized individuals. Methodology A cross-sectional study using a web-based Attitude to Mental Illness Questionnaire (AMIQ) with additional scenarios was utilized to assess stigma among resident physicians in differing specialties in a hospital training system.The research investigators collected anonymous data on demographics, characteristics, specialties, and the AMIQ. In eight vignettes, participants responded to five items using a five-point Likert scale assessing attitudes toward individuals. Results Of the 104 resident physicians enrolled in the hospital training system where the study was conducted, 58 (56%) volunteered to participate. The participating residents markedly exhibited negative attitudes toward the individual in the vignette with multiple inpatient psychiatric admissions. Residents also exhibited more negative attitudes toward individuals with schizophrenia, self-harm by way of overdose, psychedelic users, cannabis users, andalcohol problems compared todiabetic andChristian individuals. Conclusions Residents exhibited negative attitudes toward individuals with mental illness. Additional research would further our understanding of the reasons for physician bias. Moreover, GME programs and medical educators can play a crucial role in mitigating stigma among future physicians, thereby enhancing care for individuals with mental illness.

Physician justification for anti-cancer treatment decisions in the evolving oncology market.

e23317 Background: Oncology is a rapidly expanding pharmaceutical space, driven by innovative research and clinical technology. Continued growth in anti-cancer therapy has generated an exceedingly competitive market. As treatment options increase, physicians must weigh a variety of factors to make individualized care decisions. Many elements are patient-specific, but physician biases may also impact selection. As the market evolves, it is unknown whether oncology providers will shift priorities to align with contemporary findings or continue to trust in historical experiences. Methods: The Ipsos Global Oncology Monitor is an online, multi-center medical chart review of oncology patients receiving drug therapy. Over 1,900 cancer-treating physicians in the United States were screened for seniority and caseload and submitted data on 253,051 cancer patients (aggregate; all tumor types) between January 2020 to December 2023. Upon record submission, physicians were prompted to select up to three responses most associated with the reason for prescribing the reported therapy. Responses were chosen from a finite list of closed-ended options. Results: Influence of “Approved Standard of Care” fell amongst sampled physicians, cited as a reason for selecting treatment in 61% of reported annual patients in 2023, declining by 2.94 percentage points since 2020. “Biomarker results” recorded increased influence on therapy selection, rising in association with 8% of reported patients in 2020 to 11% in 2023. Within tumor-specific cohorts, “Maintain/improve quality of life” was a notable reason for drug therapy decisions in both breast and colorectal cancer patient subsets in 2023 (10% and 19% respectively). Contrary to the overall patient cohort, drug therapy choice for reported prostate cancer patients has increasingly shown association with “Approved Standard of Care” (53% in 2020 to 60% in 2023). Conclusions: Results of this study highlight the evolution of factors influencing anti-cancer treatment decisions in sampled physicians. Sampled providers appear to be shifting away from universal treatments, as shown by lowered association with “Approved Standard of Care”. Sampled physicians seem to be opting for specific therapies, demonstrated by rising influence of “Biomarker results”. Discrepancies between tumors merit expansion of research in rarer indications and emphasize the importance of diagnostic testing to continue improving quality of care. Further investigation using comparator cohort is warranted.

Patient-reported and clinical outcomes among patients with pancreatic cancer.

e23200 Background: Pancreatic cancer is associated with poor survival, high symptom burden, and psychological distress. Conventional assessments such as performance status (PS) have relied on provider-generated data to evaluate the selection of treatment and prognosis. Patient-reported outcome measures (PROMs) represent a patient-centric representation of the patient experience and are increasingly applied as tools to help improve outcomes and quality of life. However, little is known about the correlation of PROMs with ECOG PS and clinical outcomes in pancreatic cancer. Methods: We performed a retrospective analysis of patients with pancreatic cancer seen at the Henry Ford Health System between 09/2020 and7/2023, using ICD codes. The NIH’s validated and standardized Patient-Reported Outcomes Measurement Information System was used to capture 4 core domains: fatigue, pain interference, physical function, and depression. Patient-level variables and disease-specific variables were obtained by chart review from EHR. Kruskal-Wallis tests for continuous variables and or Fisher’s exact tests for categorial variables were used to compare the different ECOG scores and PROM scores and patient-level and disease-specific variables. Results: 176 patients were analyzed, with a median age of 65, 58% were male. Most patients had Stage 1 32.9% followed by Stage 4 25.9%, stage 3 22.9%, 1 32.9%. The majority had an ECOG score of 1, followed by, 0, 2, and only 10 had an ECOG PS of 3. There was no statistically significant difference in PS scores according to smoking status, race, or AJCC Stage but differed by age (P = 0.0007). PS score was not significantly associated with PROMscores on depression, fatigue, or pain interference. However, increasing PS scores were associated with a significant increase in low physical function PROM scores (P &lt; 0.0001). Conclusions: Clinician-assessed PS is a single assessment of the patient’s tolerance to therapies subject to physician bias; our study provides encouraging data on the association between PS and patients’ reported physical function. The other PROM domains did not provide additional meaningful information on the patient’s function although are part of clinical decision-making. [Table: see text]

Radio-anatomical evaluation of clinical and radiomic profile of multi-parametric magnetic resonance imaging of de novo glioblastoma multiforme

BackgroundGlioblastoma (GBM) is a fatal, fast-growing, and aggressive brain tumor arising from glial cells or their progenitors. It is a primary malignancy with a poor prognosis. The current study aims at evaluating the neuroradiological parameters of de novo GBM by analyzing the brain multi-parametric magnetic resonance imaging (mpMRI) scans acquired from a publicly available database analysis of the scans.MethodsThe dataset used was the mpMRI scans for de novo glioblastoma (GBM) patients from the University of Pennsylvania Health System, called the UPENN-GBM dataset. This was a collection from The Cancer Imaging Archive (TCIA), a part of the National Cancer Institute. The MRIs were reviewed by a single diagnostic radiologist, and the tumor parameters were recorded, wherein all recorded data was corroborated with the clinical findings.ResultsThe study included a total of 58 subjects who were predominantly male (male:female ratio of 1.07:1). The mean age with SD was 58.49 (11.39) years. Mean survival days with SD were 347 (416.21) days. The left parietal lobe was the most commonly found tumor location with 11 (18.96%) patients. The mean intensity for T1, T2, and FLAIR with SD was 1.45E + 02 (20.42), 1.11E + 02 (17.61), and 141.64 (30.67), respectively (p = < 0.001). The tumor dimensions of anteroposterior, transverse, and craniocaudal gave a z-score (significance level = 0.05) of − 2.53 (p = 0.01), − 3.89 (p < 0.001), and 1.53 (p = 0.12), respectively.ConclusionThe current study takes a third-party database and reduces physician bias from interfering with study findings. Further prospective and retrospective studies are needed to provide conclusive data.

Impact of Physician Characteristics on Late-Onset Sepsis (LOS) Evaluation in the NICU.

The threshold for a late-onset sepsis (LOS) evaluation varies considerably across NICUs. This unexplained variability is probably related in part to physician bias regarding when sepsis should be "ruled out". The aim of this study is to determine if physician characteristics (race, gender, immigration status, years of experience and academic rank) effect LOS evaluation in the NICU. This study includes a retrospective chart review of all Level III NICU infants who had a LOS evaluation over 54 months. Physician characteristics were compared between positive and negative blood culture groups and whether CBC and CRP were obtained at LOS evaluations. There were 341 LOS evaluations performed during the study period. Two patients were excluded due to a contaminant. Patients in this study had a birth weight of [median (Q1, Q3)]+ 992 (720, 1820) grams and birth gestation of [median (Q1, Q3)] 276/7 (252/7, 330/7) weeks. There are 10 neonatologists in the group, 5/10 being female and 6/10 being immigrant physicians. Experienced physicians were more likely to obtain a CBC at the time of LOS evaluation. Physician characteristics of race, gender and immigration status impacted whether to include a CRP as part of a LOS evaluation but otherwise did not influence LOS evaluation, including the likelihood of bacteremia.

A Student Teaching Assistant Program for Diversity, Equity, Inclusion, and Antiracism Curricular Enhancement.

In the United States, physician bias is exhibited early in medical training and contributes to systemic inequities within the field of medicine. A lack of diversity, equity, inclusion, and antiracism (DEI-AR) content within medical curricula drives critical gaps in knowledge and deficiencies when preparing medical students to serve patients of diverse backgrounds. At the Mayo Clinic Alix School of Medicine (MCASOM), student-led curricular reviews between 2017 to 2018 and 2020 to 2021 revealed opportunities to improve DEI-AR content within preclinical courses. Course directors expressed concern of limited expertise and time to enact effective changes. The MCASOM DEI-AR teaching assistant (TA) program aims to curate a collaborative partnership between course directors and compensated student TAs to facilitate course enhancements responsive to the prior preclinical course review while centering standardized DEI-AR best practices. As of January 2024, the program has engaged 14 TAs and partnered with 24 preclinical courses. Postcourse student evaluation responses were collected from 8 courses for 2021 to 2022 (before enhancements) and 2022 to 2023 (after enhancements). Student satisfaction with DEI-AR content is tracked through postcourse evaluations, with preliminary data demonstrating improvement after DEI-AR curricular integration (improvement of mean preenhancement and postenhancement scores of 3.81 to 4.05; t12 = 1.79, P = .21). Qualitative student comments were sorted into general categories of positive, negative, or neutral, showing a 6.25% median increase in positive perception of DEI. Plans for the MCASOM DEI-AR TA program include application of quality improvement strategies to improve program processes and outcomes. Development of a centralized dashboard that integrates course enhancement progress and ongoing feedback from evaluations is anticipated to facilitate this effort. The program additionally aims to develop partnerships with clinical clerkships, which would allow for a more comprehensive enhancement of the overall medical education experience related to DEI-AR.

Assessment of Gender Bias of Emergency Medicine Resident Physicians

Assessment of Gender Bias of Emergency Medicine Resident Physicians

Abstract 36: Clinical Guidelines May Help Mitigate the Impact of Physician Implicit Bias on Patient Care and Treatment

Introduction: We previously found that physician pro-White implicit bias was associated with the performance of low-value revascularization procedures for Black patients with claudication. These treatments are commonly considered risk greater than benefit but are not expressly discouraged by guidelines. We sought to investigate whether implicit bias is less likely to impact care in settings with well-defined Class Ia-supported guidelines. Hypothesis: We hypothesized that a physician’s implicit bias would not be associated with the performance of clinical practices as outlined in the 2016 AHA/ACC Guidelines on the Management of Patients with Lower Extremity Peripheral Artery Disease. Methods: We measured implicit bias via the race Implicit Association Test (IAT) using a sample of physicians from the Society for Vascular Surgery’s Vascular Quality Initiative (VQI). The IAT asks participants to classify sequential images of Black and White faces to positive and negative attributes. Based on reaction times and responses on the IAT, physicians were categorized as having no bias, pro-Black bias, or pro-White bias. IAT results were then weighted to reflect the overall VQI demographics and linked to peripheral revascularization data. We used mixed effects logistic regression models to assess the association of physician implicit bias category with pre-operative prescriptions of antiplatelets (ASA, P2Y12) and statins, as well as current smoking status (reported as aORs). All models included a random intercept for the physician and were adjusted for year, physician race/ethnicity, and patient factors of race/ethnicity, diabetes, and hypertension. We examined effect modification by patient race/ethnicity through the inclusion of an interaction term with physician implicit bias category. Finally, we calculated a summary index across the four primary clinical practices and assessed the association with physician implicit bias category via a mixed effects Poisson model (reported as IRRs). Results: A total of 218 physicians successfully completed the IAT and were linked to 6,588 peripheral revascularizations they completed for claudication. We found no significant associations between the physician’s implicit bias category and the performance of any of the assessed guideline metrics for their Black or White patients (Summary Index - IRR: 1.02, 95% CI: 0.98-1.06). Additionally, we found no evidence of effect modification by patient race/ethnicity (ASA - aOR: 0.91, 95% CI: 0.61-1.34; P2Y12 - aOR: 1.22, 95% CI: 0.88-1.69; Statin - aOR: 1.12, 95% CI: 0.76-1.67). Conclusions: The performance of guideline-driven practices were not associated with a physician’s measured racial implicit bias. We provide preliminary evidence that appropriately designed guidelines could be successful in combatting Black-White health inequities stemming from the implicit bias of physicians.

Transgender and gender diverse people with endometriosis: A perspective on affirming gynaecological care.

Transgender and gender diverse people presumed female at birth experience gynaecological conditions, such as chronic pelvic pain at elevated rates, estimated to impact between 51% and 72% of this population, compared to rates of up to 26.6% in cisgender women. The negative impact of these conditions is likely amplified due to limited access to safe and affirming healthcare. Despite this high prevalence rate, there is limited research investigating the prevalence, presentation or management options for trans and gender diverse people with endometriosis. Cisgender women with endometriosis report barriers to accessing care, with lengthy times to diagnosis and limited treatment options available. However, barriers for trans and gender diverse individuals are enhanced by physician bias and lack of education in gender-affirming care. This is reflected in stories of discrimination and denial of basic healthcare. A healthcare environment built on the presumption that gynaecological patients are women, others trans and gender diverse patients, which can result in avoidance of needed medical care. A lack of knowledge of gender-affirming care alongside healthcare provider bias highlights a need for gender-affirming care and bias reduction training in undergraduate healthcare provider curricula. Research to date assessing current curriculum in Australia and Aotearoa (New Zealand) shows limited inclusion of lesbian, gay, bisexual, trans, queer, intersex, asexual and other related identities content as a whole with gender-affirming care being among the least-frequently addressed topics. This review will detail barriers to accessing gender-affirming healthcare specific to gynaecology, interweaving the experiences of a non-binary individual seeking access to gender-affirming endometriosis care.

Advances in Modeling and Interpretability of Deep Neural Sleep Staging: A Systematic Review

Sleep staging has a very important role in diagnosing patients with sleep disorders. In general, this task is very time-consuming for physicians to perform. Deep learning shows great potential to automate this process and remove physician bias from decision making. In this study, we aim to identify recent trends on performance improvement and the causes for these trends. Recent papers on sleep stage classification and interpretability are investigated to explore different modeling and data manipulation techniques, their efficiency, and recent advances. We identify an improvement in performance up to 12% on standard datasets over the last 5 years. The improvements in performance do not appear to be necessarily correlated to the size of the models, but instead seem to be caused by incorporating new architectural components, such as the use of transformers and contrastive learning.

Race, ethnicity, and immune tolerance induction in hemophilia A in the United States

BackgroundIn racially diverse communities, treatment of chronic diseases can vary across racial and ethnic groups. ObjectivesTo examine healthcare disparities in hemophilia care in the United States by evaluating receipt of immune tolerance induction (ITI) among different racial and ethnic groups. MethodsIn this cross-sectional study, people with severe hemophilia A with an inhibitor who entered the Center for Disease Control and Prevention Community Counts registry between 2013 and 2017, were aged ≥5 years at study entry, and had a history of an inhibitor (n = 614) were included. The proportion of participants receiving ITI was examined according to race and ethnicity in bivariable analysis and multivariable analysis adjusting for demographic and clinical covariates. Unadjusted and adjusted prevalence ratios and corresponding 95% CIs were computed. ResultsAmong 614 participants included in the study, 56.4% were non-Hispanic (NH) White, 19.7% were NH Black, 18.4% were Hispanic, and 4.9% were Asian. ITI was received by 85.2% of participants. On bivariable analysis, ITI treatment did not vary by race or ethnicity. On multivariable analysis, NH Black and Hispanic participants were significantly less likely to receive ITI compared to NH White participants (adjusted prevalence ratio, 0.91 [95% CI, 0.84-0.99] and 0.84 [95% CI, 0.75-0.93], respectively). ConclusionAlthough the role of ITI may evolve with growing use of emicizumab and the introduction of new hemophilia treatment products, understanding characteristics that influence care, particularly race and ethnicity, where physician bias and patient mistrust can occur, will remain relevant and applicable to other complex therapies, including gene therapy.

Strategies for Combatting Health Disparities in Prioritization Schema for Medically-Necessary Time-Sensitive Orthopaedic Surgeries

Abstract: A decrease in non-emergent procedure volume was observed during the COVID-19 pandemic to conserve protective equipment, increase hospital capacity, and limit nosocomial infection. Decreasing COVID-19 infection rates, paired with increasing hospital financial pressure and concerns for patient welfare, have prompted the development of guidelines for re-introduction of medically-necessary time-sensitive (MeNTS) procedures. Such protocols have received criticism for potentially perpetuating inequities disfavoring vulnerable populations. Limited access to testing supplies and protective equipment, coupled with higher incidence of medical comorbidities attributable to social determinants of health, disadvantages vulnerable populations in seemingly objective prioritization schema. Here, we detail both an analysis of current guidelines as well as strategies aimed at mitigating these disparities (including prioritizing essential infrastructure workers, implementing questionnaires, improving scheduling communication, tracking patients via ZIP codes and insurance status, facilitating post-operative rehabilitation, acknowledging physician bias, and favoring lottery selection over first-come, first-served). These guidelines and strategies can apply to future pandemics and even routine prioritization schema.

Leading Change from Within: Student-Led Reforms to Advance Anti-Racism within Medical Education.

Racism, physician biases against Indigenous, Black, and racialized people, and the resultant poor health outcomes have been the subject of many institutional position statements and calls to action. Across Canada, undergraduate medical education programs have recognized the importance of addressing racism, but material changes to curriculum and learning environments to incorporate anti-racist lenses have yet to be actualized. To bridge a gap seen within the curriculum, the authors of this manuscript led the co-development, organization, and implementation of a student-led anti-racism initiative at the University of Calgary's Cumming School of Medicine. The initiative consisted of a class-wide anti-racism training session and a strategic review of student governance policies, including elections and decision-making processes through an anti-racist lens to advance equity within student learning environments. Anti-racism praxis was embedded within the co-creation of the anti-racism training by incorporating cultural safety and ethical engagement principles along with paid consultations with racialized students and faculty to identify pertinent topics and inform training priorities. Through this initiative, the authors offer an approach for the larger medical community to consider in their own local efforts to advance anti-racism advocacy and curricular change. This initiative highlighted the unique role of students in disrupting the status quo and modeling an anti-racist lens in their actions and self-governance.

9 “The Child's Voice”: Perceptions of Healthcare Systems for Children Aged 8-12 Referred for Neurobehavioural Concerns: A Focus Group Study

Abstract Background Providing children with a voice to tell their story and to fully participate in the plan of care has not been commonly reported in the literature. Paediatric health assessments traditionally rely on caregiver opinions and the interpretation of the child’s view rather than the child’s first voice perspective. Objectives This study focused on the experiences of children seeing a paediatrician primarily for neurobehavioural issues, such as autism and attention-deficit hyperactivity disorder (ADHD). The study was designed to provide children with the opportunity to share their thoughts directly rather than through a caregiver. Design/Methods This study, approved by the Horizon Health Network Research Ethics Board, used a qualitative design. 11 children between 8-12 years of age were recruited. These children were interviewed across three focus groups conducted using a semi-structured approach. The interview questions focused on emotions and opinions surrounding their care. Discussions were primarily led by the children. Focus groups were transcribed and analyzed using the six phases of inductive thematic analysis. Results Three overarching themes were identified: trust, boredom, and resolution (Figure 1). Trusting in their parent’s ability to communicate for them and regarding the doctor as an expert appeared as two subthemes. Children also reported feeling substantial levels of boredom at appointments, although “missing school” and “getting a treat” were reported as positives. Despite these feelings of boredom, many children expressed that the doctor provided them with a feeling of change or resolution, and that their visits were addressing their problems and needs.​ They also report disagreement may be perceived as being ungrateful for the help. Overall, children felt trust in their physician and parental intentions, along wit feeling positive about results. However, children’s views of their care are possibly influenced by the belief that decisions will be made for them, regardless of their voice. When children disagree with care, they may not voice this because of possibly perceived negative consequences. Conclusion Children must have a voice to ensure that we meet them ‘where they are’ as care providers and make goals and plans tailored to their needs, regardless of parent or physician bias or opinion. This is a cornerstone to upholding the Rights of the Child and ensuring patient-centred care. ​

Characteristics Associated With Physician Bias in Contraceptive Recommendations

ObjectiveWe aimed to examine associations between obstetrician-gynecologist (OBGYN) contraceptive recommendations and sociodemographic characteristics of patients and recommending physicians. MethodsOBGYNs affiliated with residency programs across the United States were recruited via email to participate in an online exploratory survey depicting scenarios of reproductive-age women of differing race and socioeconomic status, all other factors identical, and were asked to provide contraceptive recommendations. The χ2 test, Fisher's exact tests, and logistic regression were used to analyze recommendation differences based on physician and patient characteristics. ResultsOf 172 physician respondents, large proportions self-identified as white (74%) and attending physicians (56%) from the Mid-Atlantic (42%). In multivariate logistic regression, self-administered methods (odds ratio [OR], 0.5; 95% confidence interval [CI], 0.2–0.8) and condoms (OR, 0.5; 95% CI, 0.3–0.9) were recommended significantly less to Black high SES patients compared with white high SES patients. Non-white physicians recommended tubal ligation (OR, 0.7; 95% confidence interval [CI], 0.5–0.9) significantly less than white physicians, and recommended long-acting reversible contraception (OR, 3.3, CI 2.2–5.2) and condoms (OR, 1.4; 95% CI, 1.1–1.9) significantly more. Trainee physicians recommended self-administered methods (OR, 0.3; 95% CI, 0.2–0.4), condoms (OR, 0.2; 95% CI, 0.2–0.3), and tubal ligation (OR, 0.4; 95% CI, 0.3–0.6) significantly less than attending physicians. ConclusionsOBGYN contraceptive recommendations differed based on patients’ perceived race and SES. Recommendations also differed based on race, training level, and geographic location of the recommending physician. Results suggest that physician bias contributes to contraceptive recommendations. OBGYNs should receive education about contraceptive coercion and patient-centered decision-making so that they provide high-quality counseling to all patients.

Ethical considerations for the use of artificial intelligence in medical decision-making capacity assessments

The rapid advancement of artificial intelligence (AI) and machine learning are providing new tools to clinicians. AI tools have the potential to process vast amounts of data in a short amount of time, providing new insights and changing how we approach complicated healthcare problems. AI has the potential to assist clinicians in medical decision-making capacity assessments by providing additional insights to an evaluation process that currently lacks universal objective standards. However, despite the promise of AI in this setting, there remain significant concerns making it unlikely to replace human evaluators anytime soon. AI remains highly susceptible to biased inputs and thus biased decisions, raises questions about autonomy, and creates uncertainty for who is accountable for the ultimate decision of capacity. In this paper we explore these ethical considerations of using AI for capacity assessments. While we acknowledge AI may not be ready to replace physicians in determining patient medical-decision making capacity, these new technologies have significant near-term potential as a tool to screen patients, uncover physician biases, and guide next steps after a capacity determination has been made.