Teaching patients to advocate and ask questions about their medical care can reduce the effects of implicit bias on doctor–patient interactions
Inequalities in medical treatment and health outcomes continue to exist between Black and White Americans, including among cancer patients. Disrupting the effects of implicit racial biases held by physicians can create more equitable interactions between patients and physicians. A recent study supported by the NCI sought to test the effectiveness of patient activation (i.e., patients asking targeted questions and advocating for themselves) to circumvent doctors’ racial biases that favor White (over Black) patients using a randomized field trial design.
In this study, Black and White male actors were trained to play the role of standardized patients (SPs) who were divorced, had stage IV lung cancer, and were either “activated” or “typical” during oncology and primary care appointments. Training Black and White SPs to act similarly in each part tested whether patient activation and race were factors in regulating the effect of physician’s implicit racial bias on the quality of care. Fourteen SPs attended 181 visits with 96 physicians who were largely middle age (median age=52.3), male (62%), and white (63%). The researchers tested their hypothesis using two independently obtained measures of doctor-patient interaction quality (SP self-report and third-party coders) in addition to physician implicit association testing (IAT). Two months after the final SP visit, physicians completed a form asking whether they detected the SP actors and for specific identifiers to support their assumptions. Additionally, physicians completed IAT and matched positive and negative words with Black and White facial images displaying pained and non-pained expressions. Independent coders reviewed transcripts of the SPs visits to assess communication skills and the quality of care delivered by physicians. The actors filled out surveys rating measures such as interaction quality, perceptions of medical treatment and doctor’s empathy, and nonverbal communication.
The results from this study showed that physicians’ implicit racial bias (as measured by the IAT) predicted racially biased interpersonal treatment among “typical” SPs across ratings of interaction quality by the SPs and by the third-party coders who read the appointment transcripts. This effect was not seen in the “activated” SPs; with “activation” significantly reducing the impact of implicit bias on doctor-patient interactions. The present research does not identify the exact mechanism for this decrease in the impact of racial biases, but one possibility is that patient activation may have helped physicians to learn specific information about the SP, thus resulting in them perceiving the SP as an individual rather than as a representative of their race. Previous research has indicated that implicit biases are difficult to change however, this study indicates that intervening to reduce the effects of these biases may be a tractable strategy for improving health disparities in medical care.
Citation:
Gainsburg I, Derricks V, Shields C, Fiscella K, Epstein R, Yu V, Griggs J. Patient activation reduces effects of implicit bias on doctor-patient interactions. Proc Natl Acad Sci U S A. 2022 Aug 9;119(32):e2203915119. doi: 10.1073/pnas.2203915119. Epub 2022 Aug 1. PMID: 35914161; PMCID: PMC9371681.
Informing youth about their hereditary breast and ovarian cancer risk does not adversely affect long-term lifestyle or quality of life
The psychosocial impact of a familial diagnosis and/or treatment of breast or ovarian cancer is known to be significant on adolescents and young adults (AYA). This impact may be particularly acute among AYAs raised in families in which BRCA genetic testing is pursued, or a positive BRCA1/BRCA2 status is revealed and disclosed. While the health implications of high-risk status among AYAs are clear, less is known about the factors that are associated with psychosocial or behavioral adaptations (i.e., health-promoting, and other risk-reducing behaviors) in the adolescent/young adult phase nor into adulthood. Recently published research supported by the NCI and NHGRI sought to (1) characterize these adaptations among AYA children of mothers who had previously undergone BRCA genetic testing, and (2) examine differences in adaptation-related outcomes based on AYA and maternal characteristics.
Study recruitment was conducted in a cross-sectional, mixed-methods manner through recruitment at 4 regional cancer centers across the United States, review of electronic health records for health status verification, and application of eligibility criteria. Mother-child dyads were identified in which mothers had undergone BRCA genetic testing 1 to 5 years previously and were not currently receiving treatment for cancer. Enrolled participants completed structured telephone interviews. Researchers collected outcome measures of interest using several validated scales; these were categorized into 3 domains—cancer risk behavior, cancer cognitions, and quality of life. Demographic and clinical covariates included age, sex, race/ethnicity of mother-child dyads, maternal educational attainment, marital status, and maternal clinical characteristics.
Of the N=272 enrolled AYAs, approximately 76% of their mothers were breast or ovarian cancer survivors and 17% of mothers were BRCA+. Data analyses indicated that young adults perceived greater risks of developing cancer, and were also more knowledgeable about cancer, compared with adolescents. In contrast, adolescents were found to be more confident in being able to prevent cancer, compared with young adults. Furthermore, AYAs with mothers who survived cancer perceived themselves to have the greatest risk for developing cancer and were more knowledgeable than AYAs whose mothers did not have cancer.
In summary, this study found that genetic testing for BRCA may influence AYAs’ psychosocial and behavioral adaptations, as measured by their cancer risk behavior, beliefs about cancer, and quality of life. However, genetic testing and breast or ovarian family history information alone are insufficient for motivating behavior changes in AYA. These findings suggest that tools, resources, or interventions designed to encourage open communication with at-risk AYAs and provide education or counseling may lead to short- and long-term changes.
This study had several limitations, including a predominantly non-Hispanic White sample with limited generalizability to members of underrepresented racial or ethnic groups. Future studies are needed to confirm these results in ethnically diverse participants. Despite these limitations, this study’s findings can help to inform future directions for interventions, such as the need for more individualized educational interventions or expansion of family-based genetic education/counseling strategies. Such strategies may contribute to improved psychological well-being and health-promoting behavior changes during adolescence and beyond that could ultimately reduce morbidity and mortality from these cancers.
Citation:
McDonnell GA, Peshkin BN, DeMarco TA, Peterson SK, Arun BK, Miesfeldt S, O'Neill SC, Schneider K, Garber J, Isaacs C, Luta G, Tercyak KP. Long-Term Adaptation Among Adolescent and Young Adult Children to Familial Cancer Risk. Pediatrics. 2022 Aug 1;150(2):e2022056339. doi: 10.1542/peds.2022-056339. PMID: 35859209.
Research reveals the neural signatures underlying the effects of mindfulness training on pain regulation
Pain and pain-related problems affect a large proportion of the US population. Common pain treatments, such as medications, are not effective for everyone and have potentially serious unintended consequences, such as addiction. Nonpharmacological interventions for pain, such as mindfulness-based stress reduction (MBSR), have been shown to be a beneficial intervention for several pain-related conditions and outcomes however, the neural mechanisms underlying these effects are still unclear. In a recent study supported by the NCCIH, researchers investigated the neurocognitive mechanisms underlying the efficacy of MBSR pain interventions. The researchers had two primary aims: (1) Investigate the effects associated with short-term standardized MBSR course and, to (2) examine practice-related differences in pain processing side-by-side for MBSR practitioners and a comparison sample of long-term meditators.
The researcher conducted a randomized, controlled trial of a MBSR intervention for pain, using functional neuroimaging techniques. Healthy, meditation-naive subjects (N=115) participated in a thermal acute pain task while undergoing functional neuroimaging before and after random assignment to one of three groups: i. 8-week MBSR course (N=28), ii. an active control condition (health enhancement program [HEP]) (N=32), or iii. a waiting list control condition (N=31). To assess practice effects, a long-term meditators group (N=30) was included which consisted of participants that had participated in intensive meditation retreats and completed the same neuroimaging paradigm. Pain response was measured using self-report (intensity/unpleasantness) and objectively using neural signatures that were developed with two multivoxel machine-learning techniques. Two brain-wide signatures of pain-related activity were developed: (1) the neurologic pain signature (NPS), emphasizes nociceptive pain processing, and (2) the stimulus intensity independent pain signature-1 (SIIPS1), emphasizes stimulus-independent neuro-modulatory processes. Assessing pain using these neural signatures allows for improvements in detecting pain-related signals in the brain as well as interpreting them in psychological terms.
The results of the study showed that people who received MBSR training had a decrease in stimulus-dependent neural pain response (NPS) as compared to the active control (HEP), and from pre- to post-intervention assessment (within group), and a slight decrease as compared to the waiting list group. Similarly, the MBSR group also showed a decrease in subjective pain responses as compared to the HEP, pre- and post-intervention, and a marginal decrease relative to the waiting list group. In both the MBSR and HEP groups, only marginal decreases were observed for stimulus-independent response (SIIPS1) as compared to the waiting list group. No within-group changes in SIIPS1 response were found. For long-term meditators, the subjective pain report differed from that of nonmeditators (meditation naive), however the neural response did not differ. Among the long-term meditators, increased practice experience was associated with reduced neural pain responses as well as reduced subjective pain. Overall, standardized effect sizes for short-term training fell in the small to medium range, while effect sizes associated with long-term training fell in the medium to large range.
In summary, this study demonstrates that these neural signatures provide valid, objective measures of pain-related brain physiology and could also differentiate between two components of pain processing: NPS and SIIPS1. Mindfulness training was associated with a reduction in pain that implicate different neural pathways dependent upon the extent and context of practice. Use of neural pain signatures in clinical settings offers promise for guiding the application of mindfulness interventions for treating pain.
Citation:
Wielgosz J, Kral TRA, Perlman DM, Mumford JA, Wager TD, Davidson RJ. Neural Signatures of Pain Modulation in Short-Term and Long-Term Mindfulness Training: A Randomized Active-Control Trial. Am J Psychiatry. 2022 Jul 28:appiajp21020145. doi: 10.1176/appi.ajp.21020145. Epub ahead of print. PMID: 35899379.
