Becoming Active Bystanders and Advocates: Teaching Medical Students to Respond to Bias in the Clinical Setting.

INTRODUCTION: Incidents of bias and microaggressions are prevalent in the clinical setting and are disproportionately experienced by racial minorities, women, and medical students. These incidents contribute to burnout. Published efforts to address these incidents are growing, but gaps remain regarding the long-term efficacy of these curricular models. We developed and longitudinally evaluated a workshop that taught medical students a framework to respond to incidents of bias or microaggressions. METHODS: In October 2019, 102 Vanderbilt core clerkship medical students participated in an hour-long, interactive, case-based workshop centered around the 3 D's response behavior framework: (1) direct, (2) distract, and (3) delegate. Participants were surveyed before and after the training, and both qualitative and quantitative data were collected. A refresher workshop was offered 8 months later, which added two additional D's: delay and display discomfort. RESULTS: After the workshop, respondents' knowledge of the assessed topics improved significantly, as did their confidence in addressing both personally experienced and witnessed incidents. Respondents initially indicated a high likelihood of using response behaviors to address incidents. The workshop did not consistently modify behavioral responses to experienced or witnessed incidents. Ninety-one percent of respondents agreed the workshop was effective. DISCUSSION: This workshop provided an effective curriculum to sustainably improve participant knowledge and confidence in responding to incidents of bias and microaggressions. This resource can be adopted by educators at other institutions.

The clinical management of factor XI deficiency in pregnant women.

INTRODUCTION: Factor XI (FXI) deficiency is associated with highly variable bleeding, including excessive gynecologic and obstetrical bleeding. Since approximately 20% of FXI-deficient women will experience pregnancy-related bleeding, careful planning and knowledge of appropriate hemostatic management is pivotal for their care. AREAS COVERED: In this manuscript, authors present our current understanding of the role of FXI in hemostasis, the nature of the bleeding phenotype caused by its deficiency, and the impact of deficiency on obstetrical care. The authors searched PubMed with the terms, 'factor XI', 'factor XI deficiency', 'women', 'pregnancy', and 'obstetrics' to identify literature on these topics. Expectations of pregnancy-related complications in women with FXI deficiency, including antepartum, abortion-related, and postpartum bleeding, as well as bleeding associated with regional anesthesia are discussed. Recommendations for the care of these women are considered, including guidance for management of prophylactic care and acute bleeding. EXPERT COMMENTARY: FXI deficiency results in a bleeding diathesis in some, but not all, patients, making treatment decisions and clinical management challenging. Currently available laboratory assays are not particularly useful for distinguishing patients with FXI deficiency who are prone to bleeding from those who are not. There is a need for alternative testing strategies to address this limitation.

Change in recommendation affects influenza vaccinations among children 6 to 59 months of age.

OBJECTIVE: To evaluate the impact of the 2002-2003 recommendation to "encourage when feasible" the influenza vaccine for healthy children 6 to 23 months of age. METHODS: A cross-sectional study of children who were 6 to 59 months of age and presented to a large, pediatric resident's continuity clinic or the affiliated acute care clinic in the summers of 2002 and 2003 was performed. The influenza vaccination status of children in the winter before enrollment and factors that influenced this status were determined by parental questionnaire. RESULTS: Of 245 and 329 children in the 2002 and 2003 study populations, influenza vaccinations increased from 7% to 18%, respectively. For healthy children 6 to 23 months of age, influenza vaccinations increased from 1% in 2002 to 17% in 2003 and accounted for most of the increase seen in the study population. Multivariate analysis revealed that the strongest predictor of pediatric influenza vaccination was parental recall of a physician recommendation (odds ratio: 39.3; 95% confidence interval: 17.3-89.4 in 2003). However, 65% of parents of high-risk children did not recall a physician recommendation despite the fact that the influenza vaccine was recommended for high-risk patients during both study years. CONCLUSION: Concomitant with the 2002-2003 influenza vaccine recommendation for healthy children 6 to 23 months of age, influenza vaccinations for these children increased significantly. Because most children for whom the influenza vaccine was recommended were not vaccinated, physicians have the opportunity to increase the pediatric influenza vaccination rate by improving their recommendation strategies.