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Assessing Transgender Patient Care and Gender Inclusivity of Breast Imaging Facilities Across the United States

Learning Objective
Describe the level of commitment to inclusive environments for trans individuals at mammography centers nationally
1 Credit
Abstract

A survey on breast imaging facilities' policies and practices regarding transgender care was distributed to the membership of the Society of Breast Imaging, consisting of approximately 2500 breast radiologists across the United States. Results demonstrate that many breast imaging facilities do not have structures in place to consistently use patients' preferred names and pronouns, nor provide inclusive environments for transgender patients. All breast imaging facilities should recognize the ways in which their practices may intensify discrimination, exclusivity, and stigma for transgender patients and should seek to improve their transgender health competencies and foster more inclusive environments.

Purpose:  To evaluate transgender patient care, gender inclusivity, and transgender health-related policies at breast imaging facilities across the United States.

Methods:  A survey on breast imaging facilities' policies and practices regarding transgender care was distributed to the membership of the Society of Breast Imaging, consisting of approximately 2500 breast radiologists across the United States. The survey was conducted by e-mail in January 2018.

Results:  There were 144 survey respondents. Responses showed that 78.5% of facilities have gender-neutral patient bathrooms, 9.0% have a separate waiting area for transgender patients, and 76.4% do not have dominant pink hues in their facilities, although 54.2% have displays with female gender content. Also, 58.0% of intake forms do not ask patients to provide their gender identity, although 25.9% automatically populate with female phrases. Within the electronic health record, 32.9% lack a distinct place to record patients' preferred names and 54.9% lack a distinct place to record patients' gender pronouns. The majority (73.4%) do not have explicit policies related to the care of transgender patients. Only 14.7% of facilities offer lesbian, gay, bisexual, and transgender training.

Conclusion:  Our national survey demonstrates that many breast imaging facilities do not have structures in place to consistently use patients' preferred names and pronouns, nor provide inclusive environments for transgender patients. All breast imaging facilities should recognize the ways in which their practices may intensify discrimination, exclusivity, and stigma for transgender patients and should seek to improve their transgender health competencies and foster more inclusive environments.

Introduction

The transgender population comprises approximately 0.6% of the total US population1, and this number is expected to grow as society becomes more accepting of gender identities that do not align with one's biological sex.2 However, transgender patients are often marginalized and face significant health disparities. Transphobia, social marginalization, violence, poverty, insurance coverage issues, homelessness, employment discrimination, and other factors contribute to such health disparities.35 One survey of 6450 transgender patients found that 19% reported being denied medical care because of their gender identity and 28% had experienced verbal harassment in medical settings.6 Transgender patients have described experiences ranging from medical staff using incorrect gender pronouns and nonpreferred names to assuming that these patients are sex workers because of their gender identity.7 Experiencing transphobia, especially in medical settings, can lead to some transgender patients expressing fear and caution about discussing their transgender identities.8 As a result of such discrimination within medical settings, 33% of transgender patients reported delaying preventive care.6

Even though health disparities exist, there is limited research on transgender health, especially within radiology.9 A review of all medical research involving transgender care before June 2016 found over 200 articles within the categories of surgery, endocrinology, and mental health, among others, but studies involving radiology were lacking.10 Nonetheless, transgender patients, like cisgender patients, utilize radiological services throughout their lives.

Transgender patients may require breast imaging in particular, not just for breast cancer screening but also for gender confirmation surgeries, including masculinizing chest surgeries and breast augmentation.4 The breast cancer rate within the transgender population is uncertain, given the presence of only case reports and limited retrospective studies within this population.1123 In part due to inadequate research, guidelines for breast cancer screening for transgender patients are varied and usually differ based on a history of gender confirming breast surgery, history of hormone use, and other risk factors such as genetic mutations and family history.4,24

Besides the lack of medical consensus on proper guidelines of care, transgender patients face cultural barriers within breast imaging settings. Breast cancer is typically portrayed as a “women's cancer,” which predisposes to gendered environments in breast cancer medical settings.25 Transgender patients have described feelings of being unwelcome in these spaces, ranging from added distress to actually being asked to leave such spaces.26 These environments can lead to inadequate cancer care for these patients and an erasure of the existence of transgender patients in medical spaces.26

Addressing transgender barriers to care within radiology is crucial to create an inclusive environment and improve cultural competencies. Furthermore, awareness of a patient's gender identity can be useful during image interpretation. For example, hormonal therapy may lead to changes in breast density and other radiographic findings24,25 that radiologists should recognize when reviewing the images.

To inform recommendations for ways in which breast imaging facilities can be more inclusive and sensitive to transgender populations, we conducted this study to evaluate transgender patient care, gender inclusivity, and transgender health-related policies at breast imaging facilities across the United States.

Materials and Methods

This study of breast imaging facilities' policies did not entail human subjects research and therefore did not require oversight by the local institutional review board.

A cross-sectional survey was developed to assess breast imaging facilities' policies and practices regarding transgender patient care. The survey consisted of multiple-choice questions, with a limited number of free response items. Certain questions were only displayed when a response of “yes” was given to a relevant prior question. Five breast radiologists completed draft versions of the survey and provided feedback regarding question clarity before actual implementation.

The survey was distributed by e-mail to the membership of the Society of Breast Imaging, comprising approximately 2500 breast radiologists across the United States. Three subsequent weekly reminder e-mails were sent. The initial and reminder e-mails were sent in January 2018. Completion of the survey was optional, and individuals received no compensation for participation.

Survey responses were summarized descriptively using counts and percentages. Analysis was performed using Excel for Windows (version 16.10; Microsoft Corporation; Redmond, Washington, USA).

Results

Respondents and Facility Characteristics

The estimated survey response rate was 5.8% (144 of 2500). Tables 1 to 4 summarize the survey responses. Respondents' facilities represented a variety of practice types (38.2% academic, 2.1% government or veterans affairs, 5.6% private practice, 54.2% other or unsure) and geographic locations (9.8% rural, 39.9% suburban, 49.0% urban, 1.4% other or unsure). The majority (90.2%) of facilities see more than 10 000 breast imaging patients per year, although 58.3% of all facilities see fewer than 10 transgender patients per year (Table 1).

Table 1. General characteristics of respondents' breast imaging facilities (n = 144)

Questionn (%)
Which of the following practice types best describes your radiology practice?
Academic55 (38.2%)
Government or veterans affairs3 (2.1%)
Private practice8 (5.6%)
Other or unsure78 (54.2%)
Unanswered0 (0%)
Which of the following geographic descriptors best describes the radiology practice?
Rural14 (9.8%)
Suburban57 (39.9%)
Urban70 (49.0%)
Others or unsure2 (1.4%)
Unanswered1 (0.7%)
Approximately how many patients does the practice see per year for breast imaging?*
101–1,0007 (4.9%)
10,001–20,00056 (39.2%)
>20,00073 (51.0%)
Unsure7 (4.9%)
Unanswered1 (0.7%)
Approximately how many transgender patients does the practice see per year for breast imaging?
<1084 (58.3%)
11–2018 (12.5%)
21–506 (4.2%)
>500 (0%)
Unsure36 (25.0%)
Unanswered0 (0%)
How many total radiologists at the practice perform breast imaging?
1–10104 (72.7%)
11–5038 (26.6%)
51–1001 (0.7%)
>1000 (0%)
Unsure0 (0%)
Unanswered1 (0.7%)
Table 2. Aspects of patient experience relevant to transgender patients at respondents' breast imaging facilities (n = 144, unless otherwise specified)

Questionn (%)
Does the breast imaging facility have gender-neutral patient bathrooms?
Yes113 (78.5%)
No26 (18.1%)
Unsure5 (3.5%)
Unanswered0 (0%)
Are the breast imaging facility's physical spaces designed with dominant pink hues?
Yes32 (22.2%)
No110 (76.4%)
Unsure2 (1.4%)
Unanswered0 (0%)
Does the breast imaging facility's signs, displays, and other graphics have female gender content (eg, pictures of women or words such as female or woman)?
Yes78 (54.2%)
No57 (39.6%)
Unsure9 (6.3%)
Unanswered0 (0%)
Does the breast imaging facility have a separate waiting area for transgender patients?
Yes13 (9.0%)
No128 (88.9%)
Unsure3 (2.1%)
Unanswered0 (0%)
Do the intake forms for breast imaging patients automatically populate with female phrases (eg, she, her)?
Yes37 (25.9%)
No74 (51.7%)
Unsure32 (22.4%)
Unanswered1 (0.7%)
Do the intake forms for breast imaging patients ask patients to provide their gender identity?
Yes25 (17.5%)
No83 (58.0%)
Unsure35 (24.5%)
Unanswered1 (0.7%)
In providing a particular gender identity on the intake form, are any of the following options available? (Select all that apply)*
Transgender2 (1.4%)
NA3 (12.0%)
Prefer not to state5 (20.0%)
Unanswered19 (76.0%)
Are you aware of any complaints from transgender breast imaging patients regarding their patient experience at the practice?
Yes6 (4.2%)
No137 (95.8%)
Unanswered1 (0.7%)
Table 3. Aspects of medical care and patient records relevant to transgender patients at respondents' breast imaging facilities (n = 144, unless otherwise specified)

Questionn (%)
Does the technologist record in the intake form or patient questionnaire for breast imaging patients that the patient is transgender?
Yes79 (56.0%)
No33 (23.4%)
Unsure29 (20.6%)
Unanswered3 (2.1%)
Do the radiology reports for breast imaging examinations automatically populate with female phrases (eg, she, her)?
Yes32 (22.4%)
No105 (73.4%)
Unsure6 (4.2%)
Unanswered1 (0.7%)
Do the patient letters for breast imaging examinations automatically populate with female phrases (eg, she, her)?
Yes27 (19.0%)
No77 (54.2%)
Unsure38 (25.8%)
Unanswered2 (1.4%)
Is there a distinct place in the electronic health record to record each breast imaging patient's preferred name?
Yes60 (42.0%)
No47 (32.9%)
Unsure36 (25.2%)
Unanswered1 (0.7%)
Is there a distinct place in the electronic health record to record each breast imaging patient's preferred gender pronouns?
Yes15 (10.6%)
No78 (54.9%)
Unsure49 (34.5%)
Unanswered2 (1.4%)
Does the practice have explicit policies related to the care of transgender patients undergoing breast imaging examinations?
Yes10 (7.0%)
No105 (73.4%)
Unsure28 (19.6%)
Unanswered1 (0.7%)
Is patient's transgender status assessed at the time of scheduling breast imaging examinations?
Yes16 (11.2%)
No80 (55.9%)
Unsure47 (32.9%)
Unanswered1 (0.7%)
For patients identified as transgender at the time of scheduling, are any special considerations made in the scheduling of their breast imaging examination?*
Yes2 (12.5%)
No10 (62.5%)
Unsure3 (18.8%)
Unanswered1 (6.3%)
Table 4. LGBT policies at respondents' breast imaging facilities (n = 144, unless otherwise specified)

Questionn (%)
Does the practice have explicit policies related to transgender employees or staff?
Yes6 (4.2%)
No79 (55.2%)
Unsure58 (40.6%)
Unanswered1 (0.7%)
Does the breast imaging facility offer LGBT training?
Yes21 (14.7%)
No94 (65.7%)
Unsure28 (19.6%)
Unanswered1 (0.7%)
Is the LGBT training mandatory?*
Yes7 (33.3%)
No11 (52.4%)
Unsure3 (14.3)
Unanswered0 (0%)
What is the format of the training?*
Online8 (38.1%)
In-person5 (23.8%)
Both online and in-person5 (23.8%)
Other or unsure3 (14.3%)
Unanswered0 (0%)
What is the frequency of the training?*
One time6 (28.6%)
Annually or other recurring basis7 (33.3%)
Other or unsure8 (38.1%)
Unanswered0 (0%)
How was the training developed?*
By the radiology practice itself3 (14.3%)
By the parent organization or institution14 (66.7%)
By a separate organization or institution1 (4.8%)
Other or unsure3 (14.3%)
Unanswered0 (0%)
Which individuals at the practice receive the LGBT training? (Select all that apply)*
Radiologists18 (85.7%)
Receptionists17 (81.0%)
Technologists18 (85.7%)
Unanswered1 (4.8%)
Is your practice included in the Human Rights Campaign's Healthcare Equality Index for evaluating facilities' policies and practices related to inclusion of LGBT patients?
Yes5 (3.5%)
No27 (18.9%)
Unsure111 (77.6%)
Unanswered1 (0.7%)
Has your practice been officially recognized in any other way for its record on LGBT health?
Yes5 (3.5%)
No73 (51.0%)
Unsure65 (45.5%)
Unanswered1 (0.7%)

Transgender Patient Experience

Regarding the patient experience for transgender patients undergoing breast imaging (Table 2), 78.5% of facilities have gender-neutral patient bathrooms, and 9.0% have a separate waiting area for transgender patients. Although a majority (76.4%) of facilities do not have dominant pink hues in their facility, most (54.2%) have signs, displays, and other graphics with female gender content.

Most intake forms (58.0%) do not ask patients to provide their gender identity. However, 25.9% of breast imaging facilities automatically populate the intake forms with female phrases. Furthermore, 19.0% of patient letters automatically populate with female phrases.

In all, 4.2% of respondents (n = 6) were aware of complaints from transgender patients regarding their patient experiences at the facility. At qualitative description, two of the complaints focused on the language used at the facility: the patient was “not being addressed as he/she [sic] wanted but had not told our tech how the patient wanted to be addressed” and the “patient did not want the breasts referred to as breasts, rather chest.” Two other patient complaints focused on the gendered environment, commenting on “only pink exam gowns” available and “too much pink.” A fifth complaint was that the “patient felt excluded by being placed in a separate waiting room.” Finally, a patient complained about “not being able to get a mammogram,” without further explanation.

Medical Care and Patient Records

The majority of facilities (55.9%) do not assess patients' transgender status at the time of scheduling a breast imaging examination (Table 3). The technologist records that the patient is transgender either in the intake form or the patient questionnaire in only a small majority of facilities (56.0%). Female phrases automatically populate in radiology reports in 22.4% of facilities. Within the electronic health record (EHR), 32.9% of facilities do not have a distinct place to record a patient's preferred name, and an additional 25.2% of respondents were unsure if this option exists. A majority (54.9%) do not have a distinct place in the EHR to record a patient's gender pronouns, and an additional 34.5% are unsure if this option exists. The majority (73.4%) do not have explicit policies related to the care of transgender patients. Among respondents for whom the facility does have explicit policies (n = 10), two noted that their facility follows general recommendations for transgender patients, one noted that their facility borrows its policies from another institution, and one noted that after determining that the patient is a transgender man the facility follows the same protocol as for cisgender male patients.

Facility Policies

Only 14.7% of facilities offer lesbian, gay, bisexual, and transgender (LGBT) training (Table 4). Among the 21 facilities that offer LGBT training, 33.3% have mandatory training. In addition, 3.5% of facilities are included in the Human Rights Campaign's Healthcare Equality Index, and 3.5% were recognized in other ways for their records on LGBT health. One facility noted that they are “published on transgender breast imaging. Started registry.” The majority of facilities (55.2%) do not have explicit policies related to transgender employees and staff, and an additional 40.6% of respondents were unsure if such policies exist. Some of the existing policies were characterized as “equal treatment” and “no place for discrimination.”

Discussion

Our national survey demonstrates many breast imaging facilities' lack of well-developed policies to provide inclusive care to transgender patients. For example, many facilities do not have explicit policies to consistently document patients' gender identities, pronouns, and preferred names. Approximately a quarter of intake forms assume female gender and automatically populate with female gender pronouns, and most do not ask about patients' gender identities. Furthermore, technologists do not record patients' transgender identities in about a quarter of facilities. Many EHRs used at these facilities also lack a distinct place to record patients' pronouns or preferred names. Such data collection on gender identity is critical to enhance respectful communication and provide each patient with appropriate care.

One of the noted patient complaints emphasizes the need for upfront and open communication regarding gender identity (“not being addressed as he/she [sic] wanted but had not told our tech how the patient wanted to be addressed”). This complaint is portrayed in a manner that places blame on the patient for incomplete communication. In this regard, the complaint gives valuable insight into how to improve the clinical experience for transgender patients. This complaint also underscores the need for mandatory LGBT training such that patients are not referred to as he/she, particularly while trying to access medical care. Overall, structural policies were weak in the realm of transgender care. Few facilities offered any sort of LGBT training for their faculty and staff, and only a third of such available training was mandatory. Most facilities did not have any explicit policies for transgender care, nor any explicit nondiscrimination policies for transgender employees.

There is little research to contextualize these results for radiology practice, though some research assessing the transgender health experience has been conducted in other medical fields. Within obstetrics and gynecology, one study found that only 20% of physicians had received transgender health-specific training.27 Approximately a third of the physicians surveyed felt “comfortable” treating transgender patients, and only 80% were “willing” to perform clinical breast examinations on transgender women.27 Another study focused on transgender patient experiences within the emergency department (ED).28 Barriers to care that prevented transgender patients from accessing the ED included “fear of discrimination” and “negative previous experiences.” Patients reported inconsistent use of their gender pronouns and preferred names and interactions with some providers who did not know what the term transgender meant. One patient questioned the quality of care received in the ED after the clinical team failed to use the patient's correct pronouns, weakening the provider-patient relationship and patient engagement in the health delivery process.28 Similar scenarios have likely been experienced by transgender patients in radiology settings given that many breast imaging facilities do not consistently ask about gender pronouns.

As of 2015 regulations, under the CMS Electronic Health Records Incentive Program (also referred to as the Meaningful Use program), EHR systems are required to have the capability to collect patient sexual orientation and gender identity information.29 Implementing these systems not only would contribute to better patient care and demonstrate the facility's commitment to improving LGBT health30, but also would allow for more widespread research on the medical needs and health service utilization of the transgender population.29,31 Facilities are encouraged to adopt EHR systems that have such data visible and readily accessible for each patient. Specifically, EHRs should include dedicated space to record a patient's gender pronouns, gender identity, preferred name, and sex assigned at birth.

Intake forms and other documentation from the breast imaging facility should follow comparable standards. LGBT-sensitive intake forms include space for patients to record their preferred name and pronouns.24 Pronoun options that could be considered include not only she and he, but also they and zie/hir29, which may help to improve respectful communication between the breast imaging facility and the transgender patient. Using a nonpreferred name or pronoun when interacting with transgender patients can enhance the stigma felt in medical settings and further create barriers to care.29 Gender identity should not be assumed and should become a regular question during the intake process. Furthermore, the considerable fraction of respondents who were unsure regarding the presence of gendered language on intake forms and patient letters, as well as regarding the capabilities of the EHR to record preferred names and gender pronouns, reflects a gap of knowledge among radiologists about this fundamental aspect of transgender care at their facilities.

Although only a small minority of respondents noted the presence of LGBT training at their facilities, there is value in all health care providers and clinic staff being knowledgeable in basic transgender care and terminology.2,32 Mandatory training on transgender health-related issues could address the many gaps in equitable health care provision that transgender patients face.4,8 This training may even include billing staff, since transgender patients often face unique billing and insurance challenges.8 This training may also be accompanied by the establishment of nondiscrimination employee protections. Support of staff members who are openly LGBT may improve communication between all clinic staff and LGBT patients.

The clinic environment can serve as an initial demonstration of inclusivity. Gender-neutral bathrooms should be available for all patients and employees throughout the clinic. Visible nondiscrimination statements in the waiting room may help patients from marginalized groups feel more comfortable seeking care in the given facility.33 The physical space can be made more inclusive by not highlighting exclusively gendered signs.24 One case study noted that a transgender patient delayed seeking care for almost a year after the discovery of a breast lump, which was later found to be metastatic breast cancer, because of gendered perceptions of breast cancer. She thought that “men and women cancers are different,” and did not think she was at risk for breast cancer because she was biologically male.13 Improving the facility environment can advance faculty and staff transgender health competence as well as improve patient outcomes, retention rates, and regulatory compliance.8

Breast imaging facilities should ensure they have structures in place to provide respectful and quality care to transgender patients. Suggestions for breast imaging facilities to achieve this aim, based on guidelines from the Center of Excellence for Transgender Health at the University of California, San Francisco4, are detailed in Table 5. Mandatory LGBT training, inclusive EHRs, gender-neutral bathrooms, and welcoming environments can directly address barriers that transgender patients face in the radiology environment. Breast imaging facilities should recognize the ways in which their practices may intensify discrimination, exclusivity, and stigma for transgender patients and seek to improve their transgender health competencies.

Table 5. Suggested practices to promote an inclusive culture for transgender patients

General Recommendations*Additional Recommendations for Breast Imaging
Clinic environmentTransgender-themed images and content should be visible and accessible in waiting areas.Clinic environment should not be exclusively gendered for women.
Training and facility policiesTraining should focus on developing cultural competencies for all clinical staff and health care providers and should include popular community-based terminology. LGBT training should be a part of each employee's on-boarding process.Facilities can develop LGBT nondiscrimination policies for both patients and clinic employees.
BathroomsGender-neutral bathrooms should be available to all patients. If this is not possible, then bathrooms should have signs that clearly state that one may choose, based on their preferences, which bathroom to use.
Patient records and data collectionPatient data should include chosen name and pronouns, gender identity, and the sex listed on patient's original birth certificate. EHRs should visibly display chosen name and pronouns. Collecting gender information should be done with the “two-step process,” which includes one question on gender identity and another question on sex assigned at birth. Intake forms may include an explanation of these questions to avoid confusion.These standards of including chosen name and gender identity should also be applied to radiology reports and patient letters, which should not prepopulate with patient gender.

Further research should incorporate transgender patients' perspectives and focus on developing evidence-based breast cancer screening protocols for the transgender population. Studies have observed conflicting results regarding transgender patients' adherence rates to breast cancer screening guidelines relative to those of cisgender patients.34,35 Learning from transgender patients themselves, perhaps through focus groups7, may help guide the development of best practices for breast imaging facilities. Transgender patients have differing attitudes toward being asked about gender identity during intake versus during the clinical visit36, and understanding these perspectives would best help attenuate barriers to care within the breast radiology practice. Our survey observed that 9% of breast imaging facilities have a separate waiting area for transgender patients, though separate patient spaces have been described as both reassuring and stigmatizing by transgender patients.28 Soliciting transgender patients' voices during the process of making a breast radiology facility more inclusive would thus help complement the information yielded by the survey results.

Furthermore, recommendations for breast imaging and breast cancer screening should be delineated to provide evidence-based guidelines and improve rates of preventive cancer screening for transgender patients. Although the published incidence rates for female and male patients are 142.7 per 100 000 person-years and 1.1 per 100 000 person-years, respectively, these rates do not consider differences between cisgender and transgender patients.37 It is unknown how a history of breast surgery or hormone treatment may affect breast cancer rates and screening recommendations for transgender patients.38 For example, breast implants in a transgender woman may limit the diagnostic ability of mammography, and a history of mastectomy in a transgender man has uncertain effects on the patient's risk of breast cancer.4,39

Note that even though we have used the term transgender, we do not intend for this term to serve as a comprehensive identity or label for all gender minority patients. Other terms, such as gender nonconforming, gender nonbinary, gender-queer, and other non-cisgender identity labels are also actively used by individuals within gender minority communities.2 Health care providers should be aware of these various identity labels and their meanings.

Additional limitations of this study include those typically associated with cross-sectional surveys. The low response rate and high proportion of respondents from academic practices limit the generalizability of the findings. Furthermore, this low response rate may reflect an overall disengagement with transgender health, especially among breast radiologists in nonacademic facilities. The fact that all survey participants were members of the Society of Breast Imaging may further limit generalizability. In addition, there may have been response bias with overrepresentation of voluntary respondents from facilities that are more inclusive and have actively engaged with transgender care. Also, although the majority of respondents reported seeing fewer than 10 transgender patients per year, this may have underestimated the true number of transgender patients seen given that some patients may not be forthcoming about their gender identity in clinics and that many clinics do not have consistent methods of gender identity documentation. Finally, it is possible that multiple respondents were from the same facility; the extent to which this may have occurred cannot be ascertained from our survey approach.

Take-Home Points

  • Our national survey demonstrated that many breast imaging facilities do not have structures in place to consistently use patients' preferred names and pronouns, nor do they provide environments that are inclusive to transgender patients.

  • All breast imaging facilities should recognize the ways in which their practices may intensify discrimination, exclusivity, and stigma for transgender patients and should seek to improve their transgender health competencies to provide more inclusive environments.

  • Suggested practices for breast imaging facilities include developing intake forms, radiology reports, patient letters, and records within their electronic health systems that do not assume patient gender, as well as implementing appropriate training for their radiologists and staff.

  • Research to develop more comprehensive clinical guidelines could help standardize care and embrace transgender patients within radiological and broader health care settings.

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Disclosure Statement: Author Rosenkrantz is the ARRS/Leonard Berlin Medical Professionalism Scholar. The authors have no conflicts of interest related to the material discussed in this article.

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