Johanna Glaser

To explore the experiences of Latina immigrants with advanced breast cancer and their support networks. We conducted semi-structured interviews with low-income Latina immigrants with advanced breast cancer and their support networks (informal caregivers, physicians, and complementary medicine (CM) practitioners). Patient interviews explored patients’ illness experience and end of life (EOL) concerns. Support network member interviews focused on the relationship of the interviewee with the patient and EOL conversations. Six authors independently coded transcripts and jointly conducted qualitative thematic analysis. 72 total interviews (13 patients, 12 informal caregivers, 6 CM practitioners, and 4 physicians) revealed two themes. (1) Staying positive was a primary patient coping mechanism. (2) Patients’ language barriers and socioeconomic and immigration status posed challenges in participants’ illness experience. Appropriately addressing language barriers and social context during medical visits is crucial for effective EOL care. Clinicians should consider patients’ financial constraints and ensure support in applying for public benefits.

Background. Patient comprehension is fundamental to valid informed consent. Current practices often result in inadequate patient comprehension. Purpose. An updated review to evaluate the characteristics and outcomes of interventions to improve patient comprehension in clinical informed consent. Data Sources. Systematic searches of MEDLINE and EMBASE (2008–2018). Study Selection. We included randomized and nonrandomized controlled trials evaluating interventions to improve patient comprehension in clinical informed consent. Data Extraction. Reviewers independently abstracted data using a standardized form, comparing all results and resolving disagreements by consensus. Data Synthesis. Fifty-two studies of 60 interventions met inclusion criteria. Compared with standard informed consent, a statistically significant improvement in patient comprehension was seen with 43% (6/14) of written interventions, 56% (15/27) of audiovisual interventions, 67% (2/3) of multicomponent interventions, 85% (11/13) of interactive digital interventions, and 100% (3/3) of verbal discussion with test/feedback or teach-back interventions. Eighty-five percent of studies (44/52) evaluated patients’ understanding of risks, 69% (41/52) general knowledge about the procedure, 35% (18/52) understanding of benefits, and 31% (16/52) understanding of alternatives. Participants’ education level was reported heterogeneously, and only 8% (4/52) of studies examined effects according to health literacy. Most studies (79%, 41/52) did not specify participants’ race/ethnicity. Limitations. Variation in interventions and outcome measures precluded conduct of a meta-analysis or calculation of mean effect size. Control group processes were variable and inconsistently characterized. Nearly half of studies (44%, 23/52) had a high risk of bias for the patient comprehension outcome. Conclusions. Interventions to improve patient comprehension in informed consent are heterogeneous. Interactive interventions, particularly with test/feedback or teach-back components, appear superior. Future research should emphasize all key elements of informed consent and explore effects among vulnerable populations.

Purpose: To measure the frequency and nature of student-perceived clinician-driven health care disparities, and determine their impact on medical students’ professional development. Method: Retrospective study of fourth-year medical students at the University of California, San Francisco School of Medicine, August 2016 to June 2017. Conducted via an electronic survey asking about frequency/nature of directly witnessed health care disparities and barriers/facilitators to action during third-year clerkships; and individual, semistructured interviews focusing on clinical details and impact on students’ professional development. Results: Respondents were 103/159 students (65%). In internal medicine clerkships, a majority perceived disparities as occurring sometimes (2–7 times in eight-week clerkship) or often (at least once weekly or nearly daily) based on language barriers (90%), patients’ homelessness (77%), history of substance abuse (76%), obesity (67%), and race/ethnicity: Latino (72%), black (71%), and Asian (56%). Results from other clerkships were similar. Barriers to student action to perceived disparities included fear of poor evaluations, hierarchy/powerlessness, a “don’t speak up” culture, the desire to be a team player, limited clinical experience, and perceiving doctors as “good people” who provide disparate care unintentionally. Impact on professional development varied, ranging from students’ normalization of disparities as stemming from clinical constraints to increased motivation to provide equitable care. Conclusions: Medical students routinely witness health care disparities during clerkships, and their observations spotlight specific clinical practices. For some students, these observations lead to a normalization of disparities; for others, they heighten commitment to equity. Clinical curricula should incorporate responding to health care disparities.