"I don't want to be the squeaky wheel": Addressing bias as a leader in emergency medicine.

BACKGROUND: Implicit bias poses a barrier to inclusivity in the health care workforce and is detrimental to patient care. While previous studies have investigated knowledge and training gaps related to implicit bias, emergency medicine (EM) leaders' self-awareness and perspectives on bias have not been studied. Using art to prompt reflections on implicit bias, this qualitative study explores (1) the attitudes of leaders in EM toward implicit bias and (2) individual or structural barriers to navigating and addressing bias in the workplace. METHODS: Investigators facilitated an hour-long workshop in May 2022 for those with leadership positions in the Society for Academic Emergency Medicine (SAEM), a leading national EM organization, including 62 attending physicians, eight residents/fellows, and four medical students. The workshop utilized arts-based methods to generate a psychologically supportive space to lead conversations around implicit bias in EM. The session included time for individual reflection, where participants used an electronic platform to respond anonymously to questions regarding susceptibility, fears, barriers, and experiences surrounding bias. Two independent coders compiled, coded, and reviewed the responses using an exploratory constructivist approach. RESULTS: A total of 125 responses were analyzed. Four major themes emerged: (1) acceptance that bias exists; (2) individual barriers, including fear of negative reactions, often due to power dynamics between respondents and other members of the ED; (3) institutional barriers, such as insufficient funding and unprotected time committed to addressing bias; and (4) ambiguity about defining and prioritizing bias. CONCLUSIONS: This qualitative analysis of reflections from an arts-based workshop highlights perceived fears and barriers that may impact EM physicians' motivation and comfort in addressing bias. These results may help guide interventions to address individual and structural barriers to mitigating bias in the workplace.

Race, racism, and antiracism in emergency medicine: A scoping review of the literature and research agenda for the future.

OBJECTIVES: The objective was to conduct a scoping review of the literature and develop consensus-derived research priorities for future research inquiry in an effort to (1) identify and summarize existing research related to race, racism, and antiracism in emergency medicine (EM) and adjacent fields and (2) set the agenda for EM research in these topic areas. METHODS: A scoping review of the literature using PubMed and EMBASE databases, as well as review of citations from included articles, formed the basis for discussions with community stakeholders, who in turn helped to inform and shape the discussion and recommendations of participants in the Society for Academic Emergency Medicine (SAEM) consensus conference. Through electronic surveys and two virtual meetings held in April 2021, consensus was reached on terminology, language, and priority research questions, which were rated on importance or impact (highest, medium, lower) and feasibility or ease of answering (easiest, moderate, difficult). RESULTS: A total of 344 articles were identified through the literature search, of which 187 met inclusion criteria; an additional 34 were identified through citation review. Findings of racial inequities in EM and related fields were grouped in 28 topic areas, from which emerged 44 key research questions. A dearth of evidence for interventions to address manifestations of racism in EM was noted throughout. CONCLUSIONS: Evidence of racism in EM emerged in nearly every facet of our literature. Key research priorities identified through consensus processes provide a roadmap for addressing and eliminating racism and other systems of oppression in EM.

The Time Is Now: Racism and the Responsibility of Emergency Medicine to Be Antiracist.

The COVID-19 pandemic has shed light on the ongoing pandemic of racial injustice. In the context of these twin pandemics, emergency medicine organizations are declaring that "Racism is a Public Health Crisis." Accordingly, we are challenging emergency clinicians to respond to this emergency and commit to being antiracist. This courageous journey begins with naming racism and continues with actions addressing the intersection of racism and social determinants of health that result in health inequities. Therefore, we present a social-ecological framework that structures the intentional actions that emergency medicine must implement at the individual, organizational, community, and policy levels to actively respond to this emergency and be antiracist.

Physician-patient agreement in the assessment of allergen relevance.

BACKGROUND: The efficacy of patch testing may be enhanced by data allowing the physician to estimate the likelihood that results of a patch-test reading are relevant to a patient's dermatitis. OBJECTIVE: The goal of this study was to compare the rates of agreement between the physician's assessment of relevance at the time of final reading and the patients' report 3 months to 3 years later in regard to whether avoidance of an allergen was needed to remain free of dermatitis. We hypothesize that the agreement rates between the physician and patient relevance assessments will vary based on properties both intrinsic and extrinsic to the allergen in question. METHODS: We mailed 407 Institutional Review Board-approved questionnaires to patients and analyzed results for the 92 patients reporting greater than 80% improvement of their dermatitis. Cross-reacting allergens tested on the same patient were combined for analysis. Percent agreement was used to assess interrater concordance. RESULTS: Percent agreement regarding relevance for each allergen or group of allergens was as follows: formaldehyde and formaldehyde-releasing preservatives, 88%; neomycin sulfate, 78%; nickel sulfate hexahydrate, 71%; fragrance mix and related products, 65%; and gold sodium thiosulfate, 56%. CONCLUSION: Relevance varies between allergens. Physician assessment of relevance at the time of final reading is not the ideal method for determining allergen relevance. This has implications for when best to determine the relevance of certain allergens. For allergens with lower agreement, in particular, extended follow-up is recommended to accurately determine an allergen's contribution to a patient's allergic contact dermatitis, especially in those circumstances in which a patient's condition has not improved.

Relevance of doubtful ("equivocal") late patch-test readings.

BACKGROUND: Doubtful late patch-test readings are often not considered clinically relevant. As a result, allergens with doubtful late readings may not be disclosed to the patient, and relevant allergens may not be avoided. We hypothesize that doubtful late reactions at a day 7 reading may be relevant. OBJECTIVE: We compared the patients' assessments of relevance to the strength of reaction at the final reading 168 hours after patch test application to determine if doubtful late patch-test reactions are relevant. METHODS: Four hundred seven subjects who underwent patch testing from January 2005 to February 2008 were mailed a survey asking if their dermatitis was more than 80% better than before patch testing and whether they needed to avoid each of their positive patch-test allergens to remain free of dermatitis. Clinical charts of respondents who indicated their dermatitis was more than 80% improved were reviewed for strength of patch-test response at day 7 for each positive patch-test result, which was then compared to the patients' assessments of relevance formulated by the investigators' interpretation of the survey. RESULTS: On the basis of survey interpretation, 63% of negative (0) late readings, 79% of doubtful (?+) late readings, 85% of + late readings, 84% of ++ late readings, and 100% of +++ late readings were considered relevant. CONCLUSION: Study limitations included small sample size, lack of formal validation of questionnaire, and response bias. However, based on the patients' assessments of relevance, allergens with doubtful late reactions were considered relevant almost as frequently as were allergens with + late readings.

Validity of subject self-report for acne.

BACKGROUND/OBJECTIVE: Acne prevalence studies often use subject self-report as data source. Our aim was to evaluate the validity of acne self-report. METHODS: Responses of university students to an acne questionnaire were compared to the trained observer's concurrent examination of acne. The validity of self-report was measured by sensitivity, specificity, positive predictive value and negative predictive value. Agreement was measured by Cohen's kappa and correct classification percentage. RESULTS: The sensitivity of self-report was 0.55 (95% CI 0.47-0.63), the specificity was 0.72 (95% CI 0.63-0.80), the positive predictive value was 0.70 (95% CI 0.61-0.78), and the negative predictive value was 0.57 (95% CI 0.49-0.65). Cohen's kappa was 0.26 (95% CI 0.15-0.38) and correct classification percentage was 63. CONCLUSIONS: Validity of self-report was moderate at best and agreement was fair, indicating that college students could not accurately report that they have acne. This is likely not sufficient for clinical or research activities or to assure that individuals who self-guide their acne therapy actually have acne.