Reflexivity and positionality applied to medical practice: a study on implicit gender bias with medical students in a Swiss university.

BACKGROUND: An array of evidence shows how the presence of implicit bias in clinical encounters can negatively impact provider-patient communication, quality of care and ultimately contribute to health inequities. Reflexive practice has been explored as an approach to identify and address implicit bias in healthcare providers, including medical students. At the Lausanne School of Medicine, a clinically integrated module was introduced in 2019 to raise students' awareness of gender bias in medical practice using a reflexivity and positionality approach. The purpose of this study is to describe the gender bias that were identified by medical students, analysing their types, places and modes of emergence during a clinical encounter. It further explores how positionality supported students' reflection on the way in which social position modulates their relationship to patients. METHODS: As part of the teaching activity, medical students individually reflected on gender bias in a specific clinical encounter by answering questions in their electronic portfolio. The questionnaire included a section on positionality. We qualitatively analysed the students' assignments (n=76), applying a thematic analysis framework. RESULTS: Medical students identified and described gender biases occurring at different moments of the clinical encounter (anamnesis (i.e. patient history), physical exam, differential diagnosis, final management). They causally associated these biases with wider social phenomena such as the gendered division of labour or stereotypes around sexuality and gender. Analysing students' reflections on how their position influenced their relationship with patients, we found that the suggested exercise revealed a major contradiction in the process of medical enculturation: the injunction to be neutral and objective erases the social and cultural context of patients and impedes an understanding of gender bias. CONCLUSION: Gender biases are present in the different steps of a clinical consultation and are rooted in broader gendered social representations. We further conclude that the tension between a quest for objectivity and the reality of social encounters should be made explicit to students, because it is constitutive of medical practice.

[Gender bias in clinical management : what can we do ?] / Biais de genre dans la prise en charge médicale : que faire ?

Health data show that there are differences in clinical management based on gender. One hypothesis is that these differences in management are not intentional discrimination but are the result of implicit and unconscious biases on the part of healthcare providers. These biases influence the clinical reasoning and practice of providers. This article, using clinical examples, illustrates how reflective practice is integrated into medical teaching in Lausanne to enable students to identify their biases, control them and ensure fair and relevant care. Students are also prompted to reflect on their social positionality, as thematising the power dynamics around knowledge and social interactions helps to better understand and prepare for medical practice.

Les données en santé font état de différences de traitement médical en fonction du genre. L'une des hypothèses est que ces différences de traitement ne sont pas des discriminations intentionnelles, mais relèvent de biais implicites et inconscients des soignant-e-s. Ces biais ont une influence sur les raisonnements et la pratique clinique des soignant-e-s. Cet article, à l'aide d'exemples cliniques, illustre comment la pratique réflexive est intégrée à l'enseignement en médecine à Lausanne afin de permettre aux étudiant-e-s d'identifier leurs biais, de les contrôler et d'assurer des soins équitables et pertinents. Il est également proposé aux étudiant-e-s de réfléchir à leur positionnement social, car thématiser les dynamiques de pouvoir autour des savoirs et des interactions sociales permet de mieux comprendre et préparer la pratique médicale.

Gender/Sex Disparities in the COVID-19 Cascade From Testing to Mortality: An Intersectional Analysis of Swiss Surveillance Data.

Objectives: This study investigates gender and sex disparities in COVID-19 epidemiology in the Canton of Vaud, Switzerland, focusing on the interplay with socioeconomic position (SEP) and age. Methods: We analyzed COVID-19 surveillance data from March 2020 to June 2021, using an intersectional approach. Negative binomial regression models assessed disparities between women and men, across SEP quintiles and age groups, in testing, positivity, hospitalizations, ICU admissions, and mortality (Incidence Rate Ratios [IRR], with 95% Confidence Intervals [CI]). Results: Women had higher testing and positivity rates than men, while men experienced more hospitalizations, ICU admissions, and deaths. The higher positivity in women under 50 was mitigated when accounting for their higher testing rates. Within SEP quintiles, gender/sex differences in testing and positivity were not significant. In the lowest quintile, women's mortality risk was 68% lower (Q1: IRR 0.32, CI 0.20-0.52), with decreasing disparities with increasing SEP quintiles (Q5: IRR 0.66, CI 0.41-1.06). Conclusion: Our findings underscore the complex epidemiological patterns of COVID-19, shaped by the interactions of gender/sex, SEP, and age, highlighting the need for intersectional perspectives in both epidemiological research and public health strategy development.

Women Are Underrepresented Among Authors of Retracted Publications: Retrospective Study of 134 Medical Journals.

We examined the gender distribution of authors of retracted articles in 134 medical journals across 10 disciplines, compared it with the gender distribution of authors of all published articles, and found that women were underrepresented among authors of retracted articles, and, in particular, of articles retracted for misconduct.

The level of the gender gap in academic publishing varies by country and region of affiliation: A cross-sectional study of articles published in general medical journals.

BACKGROUND: Women are generally under-represented as authors of publications, and especially as last authors, but this under-representation may not be uniformly distributed across countries. We aimed to document by country and region the proportion of female authors (PFA) in high-impact general medical journals. METHODS: We used PyMed, a Python library that provides access to PubMed, to retrieve all PubMed articles published between January 2012 and December 2021 in the fifty general internal medicine journals with the highest 2020 impact factor according to Journal Citation Reports. We extracted first/last authors' main country of affiliation for all these articles using regular expressions and manual search, and grouped the countries into eight regions (North/Latin America, Western/Eastern Europe, Asia, Pacific, Middle East, and Africa). We used NamSor to determine first/last authors' gender and computed the PFA for each country/region. RESULTS: We retrieved 163,537 publications for first authors and 135,392 for last authors. Gender could be determined for 160,891 and 133,373 publications, respectively. The PFA was 41% for first authors and 33% for last authors, but it varied widely by country (first authors: >50% for eight countries, maximum = 63% in Romania, minimum = 19% in Japan; last authors: >50% for two countries, maximum = 53% in Romania, minimum = 9% in Japan). The PFA also varied by region. It was highest for Eastern Europe (first authors = 53%, last authors = 40%), and lowest for Asia (36% and 29%) and the Middle East (35% and 27%). CONCLUSION: We found that the PFA varied widely by country and region, and was lowest in Asia, particularly Japan, and the Middle East. The under-representation of women as authors of publications, especially in these two regions, needs to be addressed and correcting persistent gender discrimination in research should be a top priority.

Exposure of medical students to sexism and sexual harassment and their association with mental health: a cross-sectional study at a Swiss medical school.

OBJECTIVES: To assess the self-reported prevalence of sexism and sexual harassment at a Swiss medical school, and to investigate their association with mental health. Research hypotheses were an association between sexism/sexual harassment and poor mental health and a higher prevalence of sexism/sexual harassment in clinical rotations. DESIGN: Cross-sectional study as a part of ETMED-L project, an ongoing cohort study of interpersonal competences and mental health of medical students. SETTING: Single-centre Swiss study using an online survey submitted to medical students. PARTICIPANTS: From 2096 registered students, 1059 were respondents (50.52%). We excluded 26 participants (25 due to wrong answers to attention questions, and 1 who did not answer the sexism exposure question). The final sample (N=1033) included 720 women, 300 men and 13 non-binary people. MEASURES: Prevalence of self-reported exposure to sexism/sexual harassment. Multivariate regression analyses of association between being targeted by sexism or sexual harassment and mental health (depression, suicidal ideation, anxiety, stress, burnout, substance use and recent mental health consultation). Regression models adjusted for gender, academic year, native language, parental education level, partnership and an extracurricular paid job. RESULTS: Being targeted by sexism or sexual harassment was reported by 16% of participants with a majority of women (96%). The prevalence increased with clinical work. After adjusting for covariates, we found association between being targeted by sexism/harassment and risk of depression (OR 2.29, 95% CI 1.54 to 3.41, p<0.001), suicidal ideation (B coefficient (B) 0.37, p<0.001) and anxiety (B 3.69, p<0.001), as well as cynicism (B 1.46, p=0.001) and emotional exhaustion (B 0.94, p=0.044) components of burnout, substance use (B 6.51, p<0.001) and a recent mental health consultation (OR 1.78, 95% CI 1.10 to 2.66, p=0.005). CONCLUSIONS: Sexism and sexual harassment, although less common than usually reported, are behaviours of concern in this medical school and are significantly associated with mental health.

Diagnostic Performance of Individual Symptoms to Predict SARS-CoV-2 RT-PCR Positivity and Symptom Persistence among Suspects Presenting in Primary Care during the First Wave of COVID-19.

This study aimed to estimate the diagnostic performance of patient symptoms and to describe the clinical course of RT-PCR-positive compared with RT-PCR-negative patients in primary care. Symptomatic COVID-19 suspects were assessed clinically at the initial consultation in primary care between March and May 2020, followed by phone consultations over a span of at least 28 days. Sensitivity and specificity were estimated for each symptom using the initial RT-PCR result as a reference standard. The proportions of symptomatic patients according to the RT-PCR test results were compared over time, and time to recovery was estimated. Out of 883 patients, 13.9% had a positive RT-PCR test, and 17.4% were not tested. Most sensitive symptoms were cough, myalgia, and a history of fever, while most specific symptoms were fever for ≥4 days, hypo/anosmia, and hypo/ageusia. At the final follow up (median time 55 days, range 28-105 days), 44.7% of patients still reported symptoms in the RT-PCR-positive group, compared with 18.3% in the negative group (p < 0.001), mostly with hypo/anosmia (16.3%), dyspnea (12.2%), and fatigue (10.6%). The discriminative value of individual symptoms for diagnosing COVID-19 was limited. Almost half of the SARS-CoV-2-positive patients still reported symptoms at least 28 days after the initial consultation.

'The body is difficult': reproductive navigation through sociality and corporeality in rural Burundi.

The route from family planning intentions to practices is not linear, it is contingent on different social factors including the preferences of individuals and couples, their gendered positions and bargaining power, the wider political, economic and social context, and also physical and bodily circumstances. We used qualitative data collected in rural Burundi between 2013 and 2016 to explore how these diverse factors influence reproductive navigation in a context framed by uncertainty and changing social norms. We describe representations of bodily (pre)dispositions for fertility and reproduction, such as the 'natural' capacity for birth spacing or the bodily capacity to use 'natural' (having a regular cycle) and 'modern' methods (not having negative side effects) that contribute collectively to an understanding of 'the body is difficult'. We found that despite these bodily constraints, women enact embodied agency to ensure livelihoods and social status, thus framing their reproductive intentions and practices. In the context of Burundi where corporeality is key to gendered social belonging, family planning programmes fail to respond to the needs and concerns of women and their embodied reproductive experiences.

Corrigendum: Translating planetary health principles into sustainable primary care services.

[This corrects the article DOI: 10.3389/fpubh.2022.931212.].

Reflexivity as a tool for medical students to identify and address gender bias in clinical practice: A qualitative study.

OBJECTIVES: Gender bias interferes with medical care for both men and women, leading to health inequalities. Reflexivity is used in medical education to improve health provision. This study aims to understand if a reflective approach integrated in medical practice enables raising awareness of gender bias during medical school teaching. METHODS: We conducted this study in general ambulatory medicine in Lausanne Hospital, Switzerland with 160 Master's students. Through group discussions and reflection questionnaires, students were asked to discuss clinical cases they encountered focusing on potential gender bias. We analyzed the data using a thematic analysis approach. RESULTS: The reflection on the clinical reasoning steps from a real case identified gender bias at each stage of the clinical case management. The analysis revealed two factors that facilitated gender reflexivity: guidance from a gender expert and peer-to-peer exchange. CONCLUSIONS: Our study shows that a reflective approach integrated in medical practice enables raising awareness of gender bias during medical teaching. It provides students with a systematic method they can apply in their future clinical work, thus improving care processes and experiences towards more equitable care. PRACTICE IMPLICATIONS: All gender and medicine curricula should include teaching such as this linking theory and practice through reflexivity.

Translating Planetary Health Principles Into Sustainable Primary Care Services.

Global anthropogenic environmental degradations such as climate change are increasingly recognized as critical public health issues, on which human beings should urgently act in order to preserve sustainable conditions of living on Earth. "Planetary Health" is a breakthrough concept and emerging research field based on the recognition of the interdependent relationships between living organisms-both human and non-human-and their ecosystems. In that regards, there have been numerous calls by healthcare professionals for a greater recognition and adoption of Planetary Health perspective. At the same time, current Western healthcare systems are facing their limits when it comes to providing affordable, equitable and sustainable healthcare services. Furthermore, while hospital-centrism remains the dominant model of Western health systems, primary care and public health continue to be largely undervalued by policy makers. While healthcare services will have to adapt to the sanitary impacts of environmental degradations, they should also ambition to accompany and accelerate the societal transformations required to re-inscribe the functioning of human societies within planetary boundaries. The entire health system requires profound transformations to achieve this, with obviously a key role for public health. But we argue that the first line of care represented by primary care might also have an important role to play, with its holistic, interdisciplinary, and longitudinal approach to patients, strongly grounded in their living environments and communities. This will require however to redefine the roles, activities and organization of primary care actors to better integrate socio-environmental determinants of health, strengthen interprofessional collaborations, including non-medical collaborations and more generally develop new, environmentally-centered models of care. Furthermore, a planetary health perspective translated in primary care will require the strengthening of synergies between institutions and actors in the field of health and sustainability.

Preventing sexism and sexual harassment in medical schools by using Theater of the Oppressed as an interactive and reflexive tool.

OBJECTIVES: Among the measures taken to combat sexism and sexual harassment, prevention courses for medical students are one possibility. We aimed to describe the process of implementing a training course on the prevention of sexism and sexual harassment for medical students in two Swiss medical schools by using the Theater of the Oppressed as an interactive and reflexive tool within the course. The purpose of this theater was to give the students the opportunity to express themselves and to collectively look for and discuss ways to combat and escape from oppressive situations. RESULTS: This collaborative, innovative, and interactive implementation showed that different forms of a training course can be implemented with similar objectives in an adaptable and transferable manner. The interactive and reflexive Theater of the Oppressed was an appropriate option to reach the objectives. Courses were based on identifying and acting on concrete problematic situations by focusing on individual, collective, and institutional resources. Students reported a high level of satisfaction.

Talking about Climate Change and Environmental Degradation with Patients in Primary Care: A Cross-Sectional Survey on Knowledge, Potential Domains of Action and Points of View of General Practitioners.

PURPOSE: General practitioners (GPs) could play a role in mitigating climate change by raising awareness of its impact on human health and implementing changes to improve population health and decreasing environmental footprints. The aim of this study was to assess GPs' knowledge and perspectives about the health impacts of climate change. METHOD: A questionnaire was sent to 1972 GPs in the French-speaking part of Switzerland. Knowledge of the impact of environmental degradations and climate change on health and willingness to address climate change with patients, to be exemplary and to act as role models were surveyed as well as demographic characteristics of GPs. RESULTS: Respondents (N = 497) expressed a high level of self-reported knowledge regarding climate change, although it was lower for more specific topics, such as planetary health or health-environment co-benefits. Participants mostly agreed that it is necessary to adapt clinical practice to the health impacts of climate change and that they have a role in providing information on climate change and its links to human health. CONCLUSION: Most of the GPs were concerned about environmental and climate degradation. However, this study revealed a gap between the willingness of GPs to integrate the impact of climate change on health into their clinical activities and their lack of overall knowledge and scientific evidence on effective interventions. A promising way forward may be to develop co-benefit interventions adapted to the clinical setting on diet, active mobility and connecting with nature.

Trends in COVID-Related Activity in Sentinel Family Medicine Practices: An Observational Study.

Objectives: During the COVID pandemic, data collected in family medicine were scarce. The COVID-FM project aimed to monitor trends of COVID-related activity in family medicine practices of the canton of Vaud, Switzerland, during the year 2021. Methods: Practitioners were invited to join an ad hoc sentinel surveillance system. Online data collection was based on daily activity reports and monthly questionnaires. Participants categorized daily counts of consultations and phone calls into predefined categories. Data were reported and discussed on a weekly basis with public health authorities. Results: On the target of 50 physicians, 37 general physicians from 32 practices finally constituted the COVID-FM sentinel network, contributing to 901 practice-weeks of surveillance in family medicine and 604 in paediatrics. In paediatrics, COVID-related activity corresponded mostly to COVID-19 diagnostic consultations (2911/25990 face-to-face consultations = 11.2%) while in family medicine, other COVID-related topics-such as questions on vaccination-predominated (4143/42221 = 9.8%). Conclusion: COVID-related consultations constituted an important part of primary care practices' activity in 2021. Monitoring COVID-related activity in primary care provided health authorities with valuable information to guide public health action.

Use of standardized brief geriatric evaluation compared with routine care in general practice for preventing functional decline: a pragmatic cluster-randomized trial.

BACKGROUND: Although assessment of geriatric syndromes is increasingly encouraged in older adults, little evidence exists to support its systematic use by general practitioners (GPs). The aim of this study was to determine whether a systematic geriatric evaluation performed by GPs can prevent functional decline. METHODS: We conducted a controlled, open-label, pragmatic cluster-randomized trial in 42 general practices in Switzerland. Participating GPs were expected to enrol an average of 10 community-dwelling adults (aged ≥ 75 yr) who understood French, and had visited their GP at least twice in the previous year. The intervention consisted of yearly assessment by the GP of 8 geriatric syndromes with an associated tailored management plan according to assessment results, compared with routine care. Our primary outcomes were the proportion of patients who lost at least 1 instrumental activity of daily living (ADL) and the proportion who lost at least 1 basic ADL, over 2 years. Our secondary outcomes were quality-of-life scores, measured using the older adult module of the World Health Organization Quality of Life Instrument, and health care use. RESULTS: Forty-two GPs recruited 429 participants (63% women) with a mean age of 82.5 years (standard deviation 4.8 yr) at time of recruitment. Of these, we randomly assigned 217 participants to the intervention and 212 to the control arm. The proportion of patients who lost at least 1 instrumental ADL in the intervention and control arms during the course of the study was 43.6% and 47.6%, respectively (risk difference -4.0%, 95% confidence interval [CI] -14.9% to 6.7%, p = 0.5). The proportion of patients who lost at least 1 basic ADL was 12.4% in the intervention arm and 16.9% in the control arm (risk difference -5.1%, 95% CI -14.3% to 4.1%, p = 0.3). INTERPRETATION: A yearly geriatric evaluation with an associated management plan, conducted systematically in GP practices, does not significantly lessen functional decline among community-dwelling, older adult patients, compared with routine care. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02618291.

[Gender in medicine: what contribution to medical practice? Eight selected narratives]. / Le genre en médecine : quels apports pour la pratique ? Huit témoignages choisis.

In this article, we report abstracts of eight interviews, showing how clinicians use their interest in gender in their everyday practice. Clinicians report that being acquainted with a person interested by the question of gender raises their own awareness about the subject. In practice, they notice biased acquisition of knowledge due to non-inclusion of gender in research on one hand, and influence of gender stereotypes on clinical care on the other hand. Gender also influenced carriers. Some interviewed clinicians expressed they wished for more training, to reduce inequalities attributable to gender.

Dans cet article, nous rapportons de brefs extraits de 8 entrevues avec des clinicien·ne·s sensibilisé·e·s au genre, dans le but d'illustrer comment un intérêt pour ce domaine peut influencer la pratique quotidienne. Les personnes interrogées expliquent que le fait d'avoir un·e proche intéressé·e au genre les a rendues attentives à ce sujet. Dans leur pratique, elles disent avoir conscience de biais liés, d'une part, à l'acquisition des connaissances médicales ne tenant pas compte du genre et, d'autre part, à des stéréotypes de genre menant à une pratique médicale inégalitaire. Le genre a aussi un effet sur leurs carrières. Certaines personnes interrogées souhaiteraient bénéficier de plus de formation afin de diminuer les inégalités dues au genre.