Black Physicians and the Struggle for Civil Rights: Lessons from the Mississippi Experience: Part 2: Their Lives and Experiences

Little information is available on the lives and experiences of black physicians who practiced in the South during the Jim Crow era of legalized segregation. In Mississippi and elsewhere, it is a story of disenfranchised professionals who risked life, limb, and personal success to improve the lot of those they served. In this second article on this topic, we present the stories of some of the physicians who were leaders in the civil rights movement in Mississippi as examples. Because the health disparities they sought to address have, not of their own making, been passed on to the next generation of physicians, the lessons learned from their experience are worthy of consideration.     

Black Physicians and the Struggle for Civil Rights: Lessons from the Mississippi Experience: Part 1: The Forces for and Against Change

The roles of black physicians in the South in the period leading up to the Civil Rights Act of 1964 and the Voting Rights Act of 1965 have not been fully disclosed. In Mississippi and elsewhere in the South, it is a story of disenfranchised professionals who risked life, limb, and personal success to improve the lot of those they served. This first of 2 articles on the subject provides an overview of the forces for and against the struggle for civil rights and social justice in medicine in the South. We use newly available data from Mississippi as a prime example. An understanding of these forces is essential to an understanding of medical education and medical practice in this period and helps explain why the South remains in last place in most indicators of health today.     

The Structure of Medical Intensive Care Units at Training Institutions

Background

As a result of the 2011 Accreditation Council for Graduate Medical Education (ACGME) work hour guideline implementation, the structure of intensive care unit (ICU) teams at training institutions has been affected. The impact these changes have had on the current work environment has not been well described.

Denial of Human Rights: We Must Change the Paradigm of Dementia Care

In far too many instances treatment of persons with dementia has reflected a fundamental denial of basic human rights. At times, these individuals are treated worse than the treatment of animals when the five basic freedoms of animals, described by Pachana in her editorial, are implemented. A number of such examples of dehumanizing (and “de-animalizing”) persons with dementia are presented. A case is made for the position that this is the direct result of the “medicalization” of dementia and “Alzheimer Disease.” This has led to the disenfranchisement of persons with dementia and their caregivers regarding the treatment of dementia, while medical “expertise” has led to a paradigm of learned helplessness while waiting for “the cure.” While the medicalization of dementia has been a financial success in terms of funding failed researcher to find a cure, it has been a catastrophe for the quality of life of persons with dementia and their caregivers. It is time to take control of the treatment of dementia back, and especially to listen to the voices of persons with dementia. It is time to take action NOW – to become disruptive to the current paradigm. The emperor and his cure have no clothes. We deserve better. We must make this change in paradigm our mission, to demand it, and to accept nothing less. Power to the people.     

Implicit Bias among Physicians and its Prediction of Thrombolysis Decisions for Black and White Patients

Context Studies documenting racial/ethnic disparities in health care frequently implicate physicians’ unconscious biases. No study to date has measured physicians’ unconscious racial bias to test whether this predicts physicians’ clinical decisions. Objective To test whether physicians show implicit race bias and whether the magnitude of such bias predicts thrombolysis recommendations for black and white patients with acute coronary syndromes. Design, Setting, and Participants An internet-based tool comprising a clinical vignette of a patient presenting to the emergency department with an acute coronary syndrome, followed by a questionnaire and three Implicit Association Tests (IATs). Study invitations were e-mailed to all internal medicine and emergency medicine residents at four academic medical centers in Atlanta and Boston; 287 completed the study, met inclusion criteria, and were randomized to either a black or white vignette patient. Main Outcome Measures IAT scores (normal continuous variable) measuring physicians’ implicit race preference and perceptions of cooperativeness. Physicians’ attribution of symptoms to coronary artery disease for vignette patients with randomly assigned race, and their decisions about thrombolysis. Assessment of physicians’ explicit racial biases by questionnaire. Results Physicians reported no explicit preference for white versus black patients or differences in perceived cooperativeness. In contrast, IATs revealed implicit preference favoring white Americans (mean IAT score = 0.36, P < .001, one-sample t test) and implicit stereotypes of black Americans as less cooperative with medical procedures (mean IAT score 0.22, P < .001), and less cooperative generally (mean IAT score 0.30, P < .001). As physicians’ prowhite implicit bias increased, so did their likelihood of treating white patients and not treating black patients with thrombolysis (P = .009). Conclusions This study represents the first evidence of unconscious (implicit) race bias among physicians, its dissociation from conscious (explicit) bias, and its predictive validity. Results suggest that physicians’ unconscious biases may contribute to racial/ethnic disparities in use of medical procedures such as thrombolysis for myocardial infarction.     

Discovering the women ‘Foundation Fellows’ of the Royal Australasian College of Physicians

When the Royal Australasian College of Physicians incorporated in 1938, the names of 232 Foundation Fellows entered the first fellows’ register. In histories of the College, there is no mention that five of these pioneers were women. The achievements of these extraordinary women appear to have been overlooked or ignored. This is a brief account of what they achieved and the times in which they lived.     

Ethnic Differences in Secretion,Sensitivity, and Hepatic Extraction of Insulin in Black and White Americans

Hyperinsulinaemia and abnormalities in hepatic insulin extraction commonly coexist in ethnic groups with severe insulin resistance. Therefore, we compared the effects of ethnicity on glucose/insulin/C-peptide dynamics, hepatic insulin extraction, and insulin sensitivity in healthy black (n = 32) and white (n = 30) Americans. Standard oral glucose tolerance test (OGTT) and tolbutamide-modified, frequently sampled, intravenous glucose tolerance (FSIVGT) tests were performed in each subject. Insulin sensitivity index (S₁) was calculated using the MINIMOD method described by Bergman et al. Basal and post-stimulation hepatic insulin extraction were calculated by the molar ratios of C-peptide and insulin concentrations during the basal steady state and areas under the post-stimulation hormone curves, respectively. Apart from a slightly greater mean serum glucose peak response after oral glucose in the whites, mean glucose levels were identical in the blacks and whites during both stimulations. In contrast, serum insulin levels at basal and during both stimulations were significantly greater (2–3 fold) in the blacks than whites. However, the corresponding C-peptide responses were identical in both groups. The basal and postprandial hepatic insulin extraction were 33% and 45% lower in the blacks when compared to whites, respectively. The mean S₁ was significantly (p < 0.02) lower in the blacks (4.93 ± 0.46) than the whites (7.17 ± 0.88 × 10^?4 (mU l^?1)^?1). We conclude that ethnicity may be a major determinant of the mechanism of peripheral hyperinsulinaemia and insulin insensitivity in black and white Americans.     

A primer on medical education in the United States through the lens of a current resident physician

Physician training and standards for medical licensure differ widely across the globe. The medical education process in the United States (US) typically involves a minimum of 11 years of formal training and multiple standardized examinations between graduating from secondary school and becoming an attending physician with full medical licensure. Students in the US traditionally enter a 4-year medical school after completing an undergraduate bachelor’s degree, in contrast to most other countries where medical training begins after graduation from high school. Medical school seniors planning to practice medicine in the US must complete postgraduate clinical training, referred to as residency, within the specialty of their choosing. The duration of residency varies depending on specialty, typically lasting between 3 and 7 years. For subspecialty fields, additional clinical training is often required in the form of a fellowship. Many experts have called for changes in the medical education system to shorten medical training in the US, and reforms are ongoing in some institutions. However, physician education in the US generally remains a progression from undergraduate premedical coursework to 4 years of medical school, followed by residency training with an optional subspecialty fellowship.     

Do Internists and Emergency Physicians Agree on the Appropriateness of Emergency Department Visits?

The purpose of this study was to determine the levels of agreement between three methods of assessing appropriateness of emergency department (ED) visits. In particular, we tested the agreement between internists and emergency physicians reviewing the ED nurses' triage notes, containing information that might be available by telephone to an internist. For 892 adult patient ED visits reviewed, we found only moderate agreement ( κ = 0.47) between these groups. In cases of disagreement, emergency physicians were 10.3 times more likely than internists to classify those with minor discharge diagnoses as appropriate for ED care. As managed care grows, the determination of ED appropriateness may depend on open discussions between physician groups, as well as on access to timely care in office settings.     

Managing Disruptive Behavior by Patients and Physicians: A Responsibility of the Dialysis Facility Medical Director

The Centers for Medicare & Medicaid Services’ Conditions for Coverage make the medical director of an ESRD facility responsible for all aspects of care, including high-quality health care delivery (e.g., safe, effective, timely, efficient, and patient centered). Because of the high-pressure environment of the dialysis facility, conflicts are common. Conflict frequently occurs when aberrant behaviors disrupt the dialysis facility. Patients, family members, friends, and, less commonly appreciated, nephrology clinicians (i.e., nephrologists and advanced care practitioners) may manifest disruptive behavior. Disruptive behavior in the dialysis facility impairs the ability to deliver high-quality care. Furthermore, disruptive behavior is the leading cause for involuntary discharge (IVD) or involuntary transfer (IVT) of a patient from a facility. IVD usually results in loss of continuity of care, increased emergency department visits, and increased unscheduled, acute dialysis treatments. A sufficient number of IVDs and IVTs also trigger an extensive review of the facility by the regional ESRD Networks, exposing the facility to possible Medicare-imposed sanctions. Medical directors must be equipped to recognize and correct disruptive behavior. Nephrology-based literature and tools exist to help dialysis facility medical directors successfully address and resolve disruptive behavior before medical directors must involuntarily discharge a patient or terminate an attending clinician.     

Effect of Situational and Clinical Variables on the Likelihood of Physicians Ordering Physical Restraints

OBJECTIVES: To model clinical and situational variables that may affect likelihood of physicians to order physical restraints. DESIGN: Cross‐sectional, factorial survey. SETTING: One academic medical center. PARTICIPANTS: One hundred eighty‐nine physicians: interns in all specialty practices and resident and attending physicians in departments of surgery, general internal medicine, family practice, emergency medicine, and psychiatry. MEASUREMENTS: Vignettes were randomly generated using different values of six situational and eight clinical variables. Each physician received five unique vignettes for which they indicated their likelihood to order restraint on a 10‐point scale. RESULTS: Nine hundred six distinct vignettes were completed. The mean likelihood that physicians would order restraint was 3.9±3.0 (range 0 (not at all) to 9 (absolutely)). Exploratory regression analysis on physician's likelihood to restrain with independent variables of secondary diagnosis, patient age, sex, time of day, familiarity and trust with requesting nurse, patient behavior, vital signs, oxygen saturation, and dehydration explained 12.5% of variance (F=5.43, P<.001). Independent factors of unsafe patient behavior (P=.001) and secondary diagnosis of dementia (P=.06) resulted in greater likelihood of ordering restraint, whereas lack of trust in the judgment of the reporting nurse (P=.008) resulted in lower likelihood of ordering restraints. CONCLUSION: Patients' clinical status had less influence on physicians' likelihood of ordering physical restraints than the working relationship with the requesting nurse or the patient's behavior. Interdisciplinary team approaches with active physician input for nonrestraint strategies in the management of patient behavior is emphasized to minimize restraint use.     

The role of endoscopic retrograde cholangiopancreatography at an academic medical center in the era of less-invasive diagnostic tools

Evaluation of: Coté GA, Singh S, Bucksot LG et al. Association between volume of endoscopic retrograde cholangiopancreatography at an academic medical center and use of pancreatobiliarytherapy. Clin. Gastroenterol. Hepatol. 10(8), 920–924 (2012).

Many patients have pancreatobiliary diseases involving complications and comorbidities. This study shows the trends in the use of endoscopic retrograde cholangiopancreatography (ERCP) at an academic medical center from 1994 to 2009. During that time, the use of ERCPs for the treatment of bile duct stones reached a plateau and those for the treatment of pancreas divisum showed a decline. However, endoscopic therapy for benign biliary stricture and management for obstructive chronic pancreatitis increased during this period. There was a trend toward greater use of therapeutic ERCP for bile duct stenting involving metal stents and for pancreatic therapeutics. In that same period, there was an increase in the proportion of patients who had undergone unsuccessful ERCP at various other centers. Consequently, at academic medical centers, ERCP has become an increasingly complex intervention. Increasing numbers of patients with comorbidities, complications and history of failed ERCPs are being referred to academic centers to receive endotherapy.     

Assessing the origins of the European Plagues following the Black Death: A synthesis of genomic,historical, and ecological information

The second plague pandemic started in Europe with the Black Death in 1346 and lasted until the 19th century. Based on ancient DNA studies, there is a scientific disagreement over whether the bacterium, Yersinia pestis, came into Europe once (Hypothesis 1) or repeatedly over the following four centuries (Hypothesis 2). Here, we synthesize the most updated phylogeny together with historical, archeological, evolutionary, and ecological information. On the basis of this holistic view, we conclude that Hypothesis 2 is the most plausible. We also suggest that Y. pestis lineages might have developed attenuated virulence during transmission, which can explain the convergent evolutionary signals, including pla decay, that appeared at the end of the pandemics.

Researchers agree that the second plague pandemic was caused by Yersinia pestis (1–9), which arrived in Europe from Caffa transported by Genoese galleys on the Black Sea at the beginning of the Black Death (10). However, there is no consensus among researchers as to the origins of plague epidemics in Europe following the Black Death and ravaging Europe until the 19th century, as attested by historical documents (11).The two main theories are that one or more plague reservoirs remained in Western Europe during the entire second plague pandemic (referred to in the following as Hypothesis 1) (3, 4, 8, 12) or the bacteria repeatedly invaded Europe from non–Western European reservoir(s) during the same period (referred to in the following as Hypothesis 2) (6, 7, 9, 11, 13). Here, we assess these two hypotheses using a broad spectrum of evidence, including historical and archeological, genetic, evolutionary, and ecological information.     

Survey of the Royal Australasian College of Physicians examination candidates: preparation and impact on lifestyle

Candidates currently view the Royal Australasian College of Physicians' written examination as a major undertaking, knowing that approximately one-third fail on their first attempt. We anonymously surveyed New Zealand registrars who sat the written examination in 2004. We found that the majority of candidates spend long hours preparing over a several months, and that the examination had a detrimental impact on their personal lives. The results of this survey have important implications in the context of efforts to reduce the stress of doctors, and should lead to a change in either the examination itself or an increase in support provided to registrars preparing for it.