A constellation of often disabling long-term physical symptoms enduring after an acute SARS-COV-2 infection is commonly referred to as Long COVID. Since Long COVID is a new clinical entity, research is required to clarify treatment needs and experiences of individuals affected. This qualitative descriptive study aimed to provide insight into Long COVID treatment and service experiences and preferences of individuals experiencing Long COVID and the intersections with mental health.The study was conducted out of a tertiary care mental health hospital, with online recruitment from the community across Canada. A total of 47 individuals (average age = 44.9) participated in one of 11 focus groups between June and December 2022. Five focus groups were conducted with participants who had pre-existing mental health concerns prior to contracting SARS-CoV-2, and six were with people with Long COVID but without pre-existing mental health concerns. A semi-structured interview guide asked about service experiences and service preferences, including mental health and well-being services. Discussions were recorded, transcribed, and analyzed using codebook thematic analysis.When accessing services for Long COVID, patients experienced: (1) systemic barriers to accessing care, and (2) challenges navigating the unknowns of Long COVID, leading to (3) negative impacts on patient emotional well-being and recovery. Participants called for improvements in Long COVID care, with a focus on: (1) developing Long COVID-specific knowledge and services, (2) enhancing support for financial well-being, daily living, and building a Long COVID community, and (3) improving awareness and the public representation of Long COVID.Substantial treatment barriers generate considerable burden for individuals living with Long COVID. There is a pressing need to improve treatment, social supports, and the social representation of Long COVID to create integrated, accessible, responsive, and ongoing support systems. SARS-CoV-2 infection is usually associated with a short-term illness, with recovery within 7–10 days of onset of a mild infection and 3–6 weeks for severe or critical illness , 5.While the prevalence of Long COVID has yet to be established definitively, a recent U.S. study suggested that approximately 13.9% of adults infected with COVID-19 manifest some degree of Long COVID symptomatology . Meta-anThe National Institute for Health and Care Excellence (NICE) published clinical practice guidelines that recommended a holistic, integrated, and inter-disciplinary model of care for treatments of Long COVID . HoweverA plethora of research has suggested that negative mental health impacts have emerged from the COVID-19 pandemic . Social Our team’s systematic review of registered trials on Long COVID treatments identified the research under way to examine treatments for mental health challenges in the context of Long COVID . That reWhile there is an emerging body of research describing mental health challenges as sequelae to COVID-19 infection, there remains a lack of research on treatment needs and preferences of individuals whose mental health, well-being and quality of life has been impacted by Long COVID. Research is needed to understand the experiences of this vulnerable population who might have unique experiences and healthcare service needs. An in-depth understanding of their experiences of Long COVID and mental health can best be gained through a qualitative approach.This study aimed to improve our understanding of the Long COVID treatment, service experiences and preferences of individuals experiencing mental health and quality of life impacts of Long COVID, including barriers to adequate treatment. People with lived experience of Long COVID were actively involved throughout the research process to enhance study quality and relevance.This qualitative study consisted of focus group discussions, leading to codebook thematic analysis, to understand lived experience perspectives on Long COVID treatment experiences and preferences. Findings are presented from a sample of participants with Long COVID, as part of a larger study examining the perspectives of patients and service providers across disciplines. The study was conducted out of a tertiary care mental health hospital, with online recruitment from the community across Canada. This study was conducted in compliance with the Canadian Institutes of Health Research Strategy for Patient-Oriented Research , with pen = 1), COVID-19 infection within the previous 3 months (n = 2), voluntary withdrawal (n = 1), no response (n = 9), being unable to attend a focus group (n = 4) or outside of demographic quota (n = 3). Given the orientation of the study team around examining mental health factors associated with Long COVID, we purposefully sampled approximately half who self-reported having mental health challenges prior to contracting COVID-19 to more fully understand this aspect of mental health experiences (n = 23). The goal of this sampling was to gain a breadth of information about different mental health experiences in the context of Long COVID.The sample consisted of 47 participants who reported Long COVID symptoms across 11 focus group discussions. To be eligible, potential participants had to be 18 years of age or older, able to speak English, and self-identify as having Long COVID as confirmed in screening based on the World Health Organization definition, i.e., they had to describe ongoing symptoms at least three months after the onset of an acute COVID-19 infection that continued for at least two months and could not be explained by another diagnosis . ApproxiParticipant recruitment was conducted between June and December 2022. Study information was circulated via email among the research team’s networks and institutional research partners, sent to community Long COVID clinics and support organizations, posted on internal and external institutional websites at the Centre for Addiction and Mental Health (CAMH), and advertised on social media. Potential participants contacted the research team via email, text, or phone. After a brief virtual pre-screening interview to establish inclusion criteria, eligible and interested participants were asked to join a virtual meeting in which a research staff reviewed the study consent form, described the purposes of the study, and explained the procedures. After providing their informed consent, participants completed a demographic survey, hosted on REDCap software  on a secThe focus groups were conducted between August 2022 and December 2022, ranging from 61 to 89 min . Six focus groups were conducted with participants without pre-existing mental health challenges, and five with individuals who reported pre-existing mental health challenges. Present in focus groups were two research staff who facilitated the discussion, together with the participants. Clinical support was available upon request, although this was not utilized. The lead facilitator was a research staff member (ATPN), who was supported by either a post-doctoral research fellow or a PhD student co-facilitator (NYS). The discussions were conducted over WebEx videoconferencing system on a secure server and were video recorded. Notes were taken by the lead facilitator to facilitate the conversations with participants. The chat function was available as a secondary means of adding to the discussion; any comments in the chat were verbalized by the facilitators to stimulate discussion and ensure they were captured in the transcripts. Recordings were transcribed verbatim by research staff or a professional transcription service, then verified by a separate research staff member and uploaded into NVivo (Ver 12) . TranscrThe facilitators used a semi-structured interview guide that was developed in collaboration with the full study team, including lived experience partners. The interview guide consisted of 20 questions divided into three sections: (1) experiences of Long COVID, including mental health, coping, and service experiences, (2) service preferences, including a brainstorming of optimal services, (3) equity, diversity, and inclusion factors affecting Long COVID experiences and service preferences. Each section included suggested prompts to stimulate discussion. For participants with pre-existing mental health challenges, additional questions were added to understand the relationship between pre-existing mental health challenges and Long COVID experiences. The interview guide was pilot tested with members of a research team at CAMH.Data were coded and analyzed with NVivo by a research team member (ATPN) using a ‘codebook thematic analysis’ approach . It was The focus group facilitator and lead analyst is a Vietnamese female who immigrated to Canada. She has completed post-secondary education in psychology and currently holds the position of Research Analyst. Even though she does not experience Long COVID, she has a family member who survived a severe COVID-19 infection that resulted in long-term cognitive and emotional complications. Driven by her personal experience with the family member, she hopes to understand the lived experiences of Long COVID and explore appropriate service pathways for the condition. The research lead is a White female Canadian with a background in psychology, and a research focus on lived experience-engaged mental health and substance use research; she has direct experience of COVID-19 infection, but not Long COVID. Both have experiences navigating the Canadian healthcare system for other conditions from their social positions and reflected on their experiences as part of the analytical process.Participant characteristics are presented in Table We present the themes derived for two research topics: (1) experiences with healthcare services for Long COVID and (2) service and support preferences among patients with Long COVID. Each topic consists of three themes and several subthemes, illustrated in Table Participants’ experiences with healthcare services for Long COVID are represented by three themes: (1) systemic barriers to accessing care, (2) challenges navigating the unknowns of Long COVID, and (3) negative impacts on patient emotional well-being and recovery.Several systemic barriers, which are typical of the healthcare system, were reported during the focus groups; notably difficulties in accessing family physicians, long waits, and equity and social inclusion barriers were reported. Many participants faced struggles accessing primary care as a first point of contact. Not having a family physician with knowledge of their health history created a fundamental challenge for patients in understanding their Long COVID symptoms, as well as in accessing assessments and navigating treatments.It’s been hard to find a doctor. I currently don’t have a family doctor, and due to the pandemic there’s been an issue with finding doctors who are accepting patients. I’m going to see one now finally after a few months of waiting, and luckily because of a referral from a friend. But in general it does seem like prior to this friend referring me to the doctor, I don’t know where I would have gone. Nearby walk-in clinics shut down. So, I really don’t know where I would even go to have these Long COVID symptoms addressed. When I got accepted into the Long COVID centre, the wait time was any time from four to nine months—and that was three months ago. I don’t anticipate hearing from them for quite a while. Furthermore, participants reported lengthy delays in obtaining medical care, such as long waits in emergency departments and for Long COVID-specific treatments.I feel like because I’m up in Northern Ontario, that there’s not as much, and the hospitals have longer wait times, and there’s not as many doctors. […] So, like, the fact that where I’m at like geographically, there’s not as many resources available out here. So, it’s not as easy to have someone validate how you feel, or tell you like this is actually what’s going on. Participants also discussed other geographical, social, and economic factors that hindered their access to care for Long COVID. Reported barriers included living in rural areas, having more financial burden, not being permanently employed, or being from a minority group.Participants encountered Long COVID-specific challenges in accessing care as they navigated the unknowns of Long COVID. These included: (1) knowledge gaps about Long COVID, (2) inadequate services for Long COVID, and (3) illness invalidation from service providers who do not understand the condition.The lack of information for the general practitioners is really stunning, especially at this point after two and a half years of pandemic. I just find it so frustrating that more info has not come to their hands or they have not been able to be given time to study it. Participants described major knowledge gaps about Long COVID among both patients and service providers. This encompassed a lack of accurate understanding of Long COVID as an emerging syndrome and the lack of a systematic approach to investigating this condition. Specifically, participants noted that service providers were often ill-informed about the clinical manifestation of Long COVID and were thus unable to provide or refer for effective assessment and treatment.I’m on Facebook, but it’s kind of all over the map and I’m not sure if a lot of the time that’s totally applicable. I find, sometimes, it’s way too much information and it’s not a regulated source of information. So, you don’t know what’s good, and what’s bad with the information. Participants also acknowledged that they, themselves, were unfamiliar with Long COVID and therefore were unsure of how to obtain help for their symptoms. Some opted for online searches, but found the information available about Long COVID disorganized, inconsistent, and untrustworthy.Furthermore, it was clear from participants’ descriptions of their experiences that both they and healthcare providers did not understand the multi-systemic nature of the condition. Both groups tended to overlook the interconnection between physical health and mental health, and the impacts of physical health aspects of Long COVID on mental well-being.My Long COVID clinic stopped trying to do rehab because we all have these secondary conditions. We couldn’t get diagnosed or treated. I did my intake, and then they abruptly cut the actual rehab and shifted on to an educational model. I’ve heard people have similar experiences with others. I haven’t had the energy to try again. The absence of services tailored to Long COVID was highlighted, as participants discussed the lack of appropriate assessments, official diagnosis, and applicable treatments that constituted a navigational burden. Although a few participants suggested that some services were available, these were often underdeveloped or short term, despite long-lasting symptoms.Especially if you have multiple symptoms, and you have to see all the different specialists—just wrapping your head around how to go about that, and you know getting all the appointments and all the tests on this. It is a daunting task sometimes. It feels like, will we ever succeed or get to the bottom of our symptoms? Will our doctors help us? Or overall will the general medical community ever find a solution? Some participants detailed their experiences as a perplexing cycle of testing and consultation which involved referrals to multiple providers without receiving conclusive answers. The logistics involved in completing these appointments, such as time and transportation, as well as a lack of clarity about their health status, could deter patients from accessing services.I have had depression before that also, with my anxiety. I found that it was getting worse and my doctor was doing nothing but increasing my SSRIs to the point where I ended up in the ER for toxicity. […] She still refuses to acknowledge the fact that it might be long-term COVID. As the implementation of Long COVID interventions is in its early stages, participants also reported experiencing trial and error with treatments. They received a wide range of recommendations that they considered to be futile or even harmful, which potentially put their health at risk.We just have rotating nurse practitioners that come into our local health unit. […] And the first one that I saw, she just totally dismissed COVID and Long COVID. Then she just said, ‘Are you sure it’s not just mental health?’ And she just wouldn’t believe that it was Long COVID. She was trying to convince me that I was just depressed. She wanted to offer me some antidepressants and I know the difference. I know what this is and it’s nothing like that. A prominent theme in the data was that service providers did not believe in Long COVID symptoms; many participants recounted skepticism or even dismissal from service providers. The lack of conclusive medical evidence through testing, combined with knowledge gaps about Long COVID, seemed to lead doctors to question the authenticity of the condition and the veracity of the patient’s symptoms. Participants reported being trivialized and dismissed as providers undermined the significance of their symptoms, mislabeled their condition, and misdirected treatments. This could result in further service delays and symptom exacerbation.The various service access barriers produced adverse impacts on patient emotional well-being and recovery. Notably, participants expressed (1) a feeling of abandonment as they navigated the system on their own, (2) a myriad of emotional repercussions, and (3) self-stigma as a barrier to accessing care.I feel like I am doing the research myself, going back to my doctor and saying ‘Okay, I am starting to feel like a hypochondriac here. This is now what’s going on. Can we look into this? Can we look into that?’ […] It feels like I am the one trying to educate her and saying can we try this or should we look into this. I don’t feel like they are prepared at all, even after this length of time. Encountering a lack of information and resources, participants found themselves neglected by the healthcare system and were forced take on the roles of researcher, navigator, and self-advocate. They described educating themselves and doctors about Long COVID, inquiring broadly for possible interventions, and advocating for themselves during healthcare visits. Participants believed they had to ‘fight the Long COVID battle’ without proper assistance from the healthcare system.Unfortunately, it just comes down to, they just tell me to get some rest. And take some vitamins and the time. It’s frustrating, because it doesn’t seem to help some days. Through negative experiences with healthcare, participants described a myriad of emotional repercussions, which include frustration, anxiety, stress, and hopelessness. Frustration would arise from participants’ communication with service providers, to whom they had to repeatedly explain their symptoms and plead for help, without reciprocal validation from providers. Participants also felt frustrated with the lack of conclusive testing results, effective interventions, and definitive answers.Yeah, as they say, I have often felt that I am on trial with WCB [workers compensation board]. I understand that a lot of people, if they are on an insurance company—again, you feel like they think you are faking it or something, when that’s not true. But when the traditional medical test say ‘Yup, heart’s good, chest good,’ why do you have burning chest pain for a year and a half? You know, it is unbelievably stressful—really, really stressful. Anxiety and stress were also common emotional outcomes. Participants were fearful of the future and wondered whether they would ever receive appropriate help. They were overwhelmed by the pressure of having to justify the legitimacy of their illness to gain access to services and assistance.I’m not going to get anything out of this. I’ll be dead long before they fix Long COVID, but hopefully we can…fix it for the next group who get it. Ultimately, this led to a sense of hopeless about the possibility of receiving treatments and recovering.I know that our healthcare system is underwhelmed you know, or you know, overwhelmed and underfunded right now. And you know what? I have that guilty feeling is that here we are bringing something else up that they have to deal with. After disappointing experiences with services, many participants considered themselves a burden to the healthcare system and an obstacle to their own healing. A sense of guilt emerged, as participants believed they were initiating a new problem for medicine, taking away care from others, and being not “sick enough” to merit services.It is very hard to find people who validate that your experiences are actually real. I actually thought I was going crazy the first year. Participants also questioned the severity of their illness and blamed their pre-existing physical and mental health conditions for the ongoing Long COVID symptoms.And then I find, you get more frustrated with the whole process. Because you are not really getting any help, so then you don’t want to even look for help. Due to the complicated process of obtaining treatments, disbelief from providers, and self-stigma, many participants were hesitant to discuss their Long COVID symptoms with health professionals or access medical services. Some chose to address the illness using informal approaches, while others tried to ignore the symptoms and simply wait for improvement. Participants admitted that the tendency to avoid medical care for Long COVID further delayed important treatments and potentially resulted in symptom persistence.While challenges with services and providers were widely discussed during the focus groups, a few participants conveyed their gratitude for their experiences with understanding healthcare professionals and effective support programs. Patients felt valued when their providers expressed validation of their condition, showed patience with the ongoing learning gap, and suggested incremental rehabilitation for their symptoms.So, my insurance case worker, she has been wonderful. She gets, she is the one who helps me the most to get me to stick to a bit of a schedule and you know let’s see how much you can do three days a week. Try and focus on like an online course or something, two hours three days a week just so that to see what I am capable of. The second area of inquiry was participants’ service and support preferences for Long COVID. Three themes were constructed: (1) developing Long COVID-specific knowledge and services, (2) enhancing supports for financial well-being, daily living, and building a Long COVID community, and (3) improving awareness and public representation of Long COVID.Participants called for more Long COVID-specific supports, which they believed requires the development of knowledge, together with services that should be holistic, integrated, multidisciplinary, accessible and well-informed.Participants described how knowledge about Long COVID should be built upon scientific investigation, which may lead to applicable testing approaches and official diagnoses. To close the learning gap, participants felt that more inquiry into risk factors, clinical manifestations, and possible interventions for Long COVID should be prioritized. As patients sought explanations for their illness, they felt that research is needed to inform physicians of more deliberate assessment strategies and legitimize the Long COVID diagnosis in the absence of alternative causes.It would be helpful to have it, like, in person but also in a digital ways like an app or computer website. It’s all, like, a one-stop shop for like information, coping mechanisms, people experiencing different symptoms. Because it’s so new, not a lot of people really know much about it or what the symptoms are and what people are going through. To have a one-stop shop with all different types of information and resources and all of that. In addition, participants described a need for a single source of accurate and up-to-date information about Long COVID, to keep patients and families well-informed and guide them in accessing healthcare services. Participants suggested that centralized information, potentially in digital format, could alleviate their confusion and anxiety, and potentially allow for knowledge exchange among patients.I have been getting quite a few supports that I found helpful. That if I were to create my own model, I would carry them into it. And the ones that have been the most helpful are physiotherapy, occupational therapy, and psychotherapy for all reasons that we’ve already touched on. I think we all have had challenges with our mental health before. For Long COVID, I would like support for both mental and physical symptoms. I would like a multidisciplinary approach with doctors, nurses available, as well as physical therapists, social workers, psychotherapist who can help support Long COVID. Participants suggested that Long COVID-specific healthcare services be holistic, integrated and multi-disciplinary, while remaining accessible and well-informed. Emphasizing the complexity of Long COVID, participants recommended that future assessments and interventions leverage the diverse expertise of multiple types of providers to offer more coordinated and comprehensive care. In addition to medical professionals such as family physicians, nurse practitioners, and medical specialists, other types of healthcare professionals should also be involved, notably physiotherapists, occupational therapists, and social workers. The integration of personalized, long-term rehabilitation services was also highlighted to help patients regain independent living.The other thing, and I think [Participant 4] said, it is just this whole notion of integrating services. So, there are aspects there are psychosocial or physical or psychological. Or, it’s all of those things, the whole sort of mind-body-spirit connection. If you’re not feeling well in one of those areas, it’s going to have impact on the others. That’s a given, especially for something that’s so overwhelming as COVID. Participants wished for a holistic approach in which physical, mental, and emotional well-being are equally prioritized. They wanted service providers to acknowledge the interconnection between different components of health and understand that neglecting one component can affect others.The reality is we all need counselling of some sort to support us. Participants emphasized that mental health support for Long COVID, through psychologists or psychotherapists, should be considered equally important as services for physical and cognitive health.Balance between medical support, holistic support and mental wellness support. And again, it has to be culturally safe and supported .I think it is much easier to do virtually than in-person, just because of the social anxiety. I don’t wanna have to be physically—just the fear of leaving the house to go and grasp what’s that gonna feel like in-person. It’s just easier to pop in an out virtually and not. I don’t know, it helps. I can’t explain why but it does. In addition, service affordability, accessibility, and availability were highlighted. Participants expressed their need for the immediate implementation of accessible Long COVID-specific healthcare services, with walk-in services and regular follow-up. Participants wanted flexibility, including virtual, in-person, and hybrid delivery. They also wanted culturally sensitive and trauma-informed services that acknowledge systemic and personal barriers to accessing healthcare.In addition to formal services, participants also reported seeking informal and instrumental supports, including (1) financial support, (2) support for wellness, daily living and coping, and (3) building a Long COVID community.That’s a big piece of it, the financial support, because this entire time, I’ve also just been worried about how I’m going to pay my rent, how I’m going to eat and trying to figure out ways to make money, if this is a new normal. How am I going to survive this? Participants reported that Long COVID imposed significant financial burdens, impeding the ability to maintain a stable income and incurring substantial healthcare costs. Financial pressure and associated health anxiety elicited concerns among patients about their future and that of their family. As a result, many participants called for increased financial assistance from the government to help them manage daily expenses and access medical services.e.g., cooking, cleaning), obtaining assistive devices , and maintaining daily well-being. They wanted support in adopting physical exercises tailored to their fatigue and brain fog, acquiring knowledge about nutrition and sleep hygiene, and practicing coping strategies for mental health, like meditation and breathing.But the biggest thing that I’m finding is there isn’t any support for us chronic fatigue people to be able to help with our daily living tasks. That is so hard. For me, showering is hard. [Participant 3], I think you were saying earlier about cleaning around your place and stuff like that. It is really difficult… .I think the holistic piece is really important. I would love to have somebody to work out a wellness plan with me, you know? And hold me accountable to that—that would be something that would be super helpful. With people who understand it and acknowledge long- term COVID and get some of the struggles that come with it. Participants also identified a need for assistance with performing the activities of daily living Participants expressed a desire to connect with other people who are experiencing Long COVID symptoms through workshops, discussions, or support groups. This would give them a forum to share their stories, exchange support and knowledge, and build an understanding community.Group activities like these would allow for an open and safe environment for individuals with Long COVID to normalize their illness, alleviate social isolation, experience empathy from others, and increase their mental resilience.Lastly, participants emphasized that greater awareness of Long COVID is an essential component of recovery, which can be achieved through education, training, and an accurate public representation.But making sure people like caregivers, that they have the resources and the information and the… Yeah, if they were able to access an app with all the information and resources to help me when I was not able to help myself, then that would be incredible. I thought, why aren’t they teaching the people in the hospitals about COVID and Long COVID so they have some understanding? […] I just feel like there should have been informational sessions at hospitals with some semblances of understanding of what we were going through. Participants highlighted the need to enhance the understanding of Long COVID through education and training for service providers, patients, families, and employers. To improve service experiences, participants considered it imperative that physicians receive up-to-date training about Long COVID, show compassion and listen actively to their patients, while recognizing the reality of the condition. Participants suggested information sessions for providers and patients to help recognize Long COVID symptoms, understand the relationship between physical and mental health, and guide treatment seeking. Additionally, they felt that education for family members and employers should aim at supporting daily living and providing appropriate work accommodations.So, it is unbelievably stressful and it is disturbing to me that we are kind of swept under the carpet. I used to get so frustrated when I watched the daily numbers, you know, they put at the bottom of the newscast—how many people have recovered from COVID, how many people had died, no mention about Long COVID. It’s like it doesn’t even exist. So, when it doesn’t exist, and you say you have it, people kind of shake their head a little bit .Participants advocated for building an accurate public representation of Long COVID, to reduce stigma and generate public support for patients.Participants expressed the wish that the government and the media would inform the public of the existence and prevalence of Long COVID. Raising awareness of the impairing chronicity and indiscriminate nature of Long COVID, in addition to shifting the blame away from patients, would encourage them to accept the condition, access healthcare services, and reach out to supportive communities.This study examined patient perspectives on services and treatment needs for mental health and recovery in the context of Long COVID. Combining the experiences of patients with and without pre-existing mental health challenges as no group differences were identified, the results revealed three key themes about patient experiences when accessing services for Long COVID: (1) systemic barriers to care, (2) challenges navigating the unknowns of Long COVID, and (3) negative impacts on emotional well-being and recovery. In addition to a paucity of informed providers and other barriers in healthcare, participants struggled with insufficient knowledge and services for Long COVID, as well as experiencing invalidation from service providers. The unknowns of Long COVID causes emotional distress among patients and provokes self-stigma, resulting in further hesitation to access care. Participants called for substantial improvements in Long COVID care and pinpointed three areas of focus for service implementation: (1) developing Long COVID-specific knowledge and services, (2) enhancing support for financial well-being, daily living, and building a long COVID community, and (3) improving awareness and the public representation of Long COVID.The current literature on lived experiences of Long COVID and healthcare services in European countries has revealed the absence of a well-defined care pathway for Long COVID; reflected in inadequate services and supports from service providers, this has led to considerable emotional turmoil and service mistrust among patients , 29, 30.To address service gaps and access barriers, participants called for an accessible offering of holistic, integrated, multidisciplinary services specific to Long COVID, alongside accurate and accessible informational resources for clinicians and patients. Indeed, Long COVID clinical practice guidelines, which were developed with people with lived experience, recommend integrated and multi-disciplinary care . This isImportantly, patients described invalidation and discrimination during encounters with healthcare professionals, reporting a sense of stigma that compounded the negative emotional impacts of Long COVID. In the healthcare context, epistemic injustice refers to the unfair dismissal of patient experiences and undermining patient credibility as an illness informant . Long COAs the COVID-19 pandemic is on a downturn, interest in the virus and its aftermath appear to be on the decline. However, for the people living with Long COVID, continuing impacts require ongoing investigation and treatment. Patient treatment preferences align with some, but not all, of the research currently under way for mental health and Long COVID . It is tThe results of this study should be interpreted in the context of its strengths and limitations. Firstly, we adopted a patient-oriented research approach and worked closely with lived experience advisors throughout different stages of the project , which eHowever, there are a number of limitations to keep in mind. While the sample size was sufficient for qualitative research, due to the range of symptoms and experiences of Long COVID by individuals, it is possible that some patient experiences may have been missed. There was diversity in the sample across a range of characteristics; however, greater diversity in sociodemographic status and mental health experiences might have generated different findings, with a particular emphasis on minority populations such as Indigenous peoples, LGBTQ + individuals, and newcomer/immigrant populations, among others. It is also possible that those most severely affected by Long COVID were not reached. While discussions revealed that there were at least some participants who may have been influenced by service scarcity specific to living in rural areas as opposed to urban areas, we cannot describe this in detail since we did not collect this demographic variable. It is also of note that the COVID-19 pandemic has been a rapidly evolving phenomenon; the experiences of individuals living with Long COVID earlier in the pandemic may differ from those contracting it more recently.Our findings show that individuals living with Long COVID are experiencing substantial barriers to treatment and support, including general healthcare system barriers and additional barriers specific to the condition. Negative experiences of treatment and care are generating considerable burden for this population, which complicate an already complex health experience. There is a pressing need to improve treatment, social supports, and the social representation of Long COVID to create integrated, accessible, continuous, and responsive support systems, with potential application to other conditions with similar manifestations. People with Long COVID should be engaged in research and service development initiatives to create patient-centered service pathways.


Conducting a systematic review and meta-analysis to synthesize previously obtained results regarding the relationship between interest in cosmetic surgery and personality traits.A series of criteria were applied  in order to decide which existing studies could be considered eligible for inclusion in the meta-analytic procedure. The identification of research that met the eligibility criteria was carried out with the help of the electronic search function in the following databases: ScienceDirect, PsycInfo, Web of Science, Scopus, Springer, and PubMed. Following this approach left 13 studies that were then subjected to the final analysis and included in the meta-analysis.The researchers’ expectations were partially supported by the results of the analyses, thus demonstrating the existence of a significant relationship between perfectionism , appearance-based rejection sensitivity, and interest in pursuing esthetic surgery.Identifying these relationships will allow cosmetic surgeons to understand both the mechanisms underlying this decision and the need for psychological assessment/counseling before patients undergo such procedures. It will also allow psychologists to develop best practice guidelines for how they relate to the patient before they perform cosmetic surgery. At the same time, psychotherapists will be able to devise targeted and personalized interventions for each personality profile, so that the decision to undergo an esthetic operation is not made based on a dispositional trait . In recent times, we have been witnessing a considerable increase in the number of people wishing to modify certain parts of their bodies by means of various techniques and esthetic interventions. According to surveys carried out by the International Society of Aesthetic Plastic Surgery, from 2020 to 2021 there was a 19.3% increase in esthetic procedures performed globally, with liposuction being the most common surgical procedure and Botox injection the most common non-surgical one. We can also observe that, in 2021 as in 2020, breast augmentation was the most common surgical procedure among women and blepharoplasty among men. Turning to non-surgical interventions, treatment with Botox was the most popular among both women and men, with a striking interest in this procedure among young people of 18 or even less; 106,033 such procedures were performed on young people aged 18 or under in 2021 .These statistics illustrate the desire felt by very many people to improve their physical appearance in order to feel better about their own bodies, even from a very tender age; this phenomenon can be seen in all age categories (>18 to over 65). Although this desire is understandable, the decision to undergo cosmetic surgery needs to be taken after due consideration of all the potential effects (both positive and negative) of an intervention of this type, since minimizing the risks and not giving detailed attention to them can lead later to results that affect patients’ physical and psychological well-being . BesidesCosmetic surgery is a form of biomedical practice performed through various types of invasive procedures that aim to modify the patient’s bodily features so that he perceives his physical appearance as more desirable and attractive . StudiesAs can be seen, the reasons underlying interest in following an esthetic intervention are quite varied for all age categories and we already have a well-known instrument to assess people’s motivation for embarking on such a procedure, which is precisely why it is essential to develop theoretical models that present, at a general level and for the entire population, social and intrapersonal predictors of the desire to undergo an esthetic operation.Over time, several theoretical models have been tried in an attempt to explain the psychological mechanisms behind the decision to undergo an esthetic procedure. Most previous research studies have as their theoretical basis the tripartite influence model , which hBased on the tripartite influence model, we can observe how external factors, such as social media or interactions with those close to you , contribute to the internalization of the culturally and societally imposed model of beauty, to the comparing of your physical appearance with that of others, and subsequently to the desire to undergo cosmetic surgery to change certain parts of the body with which you are not satisfied.Another perspective that attempts to explain the motivation behind interest in pursuing cosmetic surgery is body objectification theory , which fIt is vital to mention that this theory can be associated in different situations with the tripartite influence model, which proposed three sources of influence  that contribute to people’s attitude toward strategies to change their physical appearance. Internalizing messages from these three sources of influence can lead to self-objectification of the body, which over time can lead to a desire for change.In addition to the two major perspectives that have tried to explain the motivation underlying the decision to request an esthetic surgical procedure, the specialist literature also regards personality as a determining factor for interest in such operations. Given the growing interest in these interventions, it is important to also address the role played by personality in determining positive attitudes toward them, since more than 47% of those who choose to undergo cosmetic surgery are likely to meet the criteria for a diagnosis of a specific mental disorder . One of Regarding the Big Five model of personality, studies have shown that neuroticism is associated with low body esteem , emotionAlso, the personality traits proposed by the Dark Triad  were associated with aspects related to body image. Machiavellianism represents a risk factor and narcissism represents a protective factor regarding body image problems developed through self-objectification . NarcissAlong with the personality types described by the Dark Triad and Big Five theories and frequently associated in the specialist literature with the desire to undergo cosmetic surgery, other traits that do not necessarily belong to a specific and well-known theoretical model have been studied recently in connection with the probability that a person will opt for esthetic surgery, along with other variables that are crucial in clarifying the reasons why people resort to such procedures.One of these traits is appearance-based rejection sensitivity, defined as a dispositional tendency that involves exaggerated reactions by people when they believe they will be rejected on the basis of their physical appearance . ResearcAnother relevant trait is perfectionism. This personality trait was conceptualized by We can thus observe that people who want to undergo an esthetic intervention may have various psychological characteristics that can affect their taking of such a decision. It is therefore recommended that they be evaluated by cosmetic surgeons armed with relevant information, with a view to the identification of any personality disorder. The surgeon will then know exactly how to relate to them . AlthougAlthough there are studies that investigate the link between personality traits and interest in having an esthetic operation, none of those so far seen by the authors gives a quantitative meta-analysis that looks specifically at the relationship between these variables. Thus, by carrying out this systematic review and the present meta-analysis, we aim to (1) synthesize the results obtained up to now by researchers regarding the abovementioned relationships and (2) analyze their scale. Identifying these relationships will allow esthetic surgeons to understand both the mechanisms underlying this decision and the need for psychological consultation before a person undergoes such a procedure. It will also allow psychotherapists to carry out intervention programs to help the people in question make the most beneficial decision for their physical and mental well-being. Furthermore, knowing the existence of the association between different kinds of personality traits  and acceptance of cosmetic surgery can be the starting point for defining future studies that are based on predictions or analyze causal relationships. In this way, the practitioners will know how to use a personalized approach with every patient based on his personality. Also, significant associations between personality traits and interest to undergo cosmetic surgery can encourage the implementation of treatment protocols based on patients’ personality. We used PRISMA guidelines in order to answer these research questions .research design, only those that reported Pearson correlations between interest in undergoing an esthetic operation and a particular personality trait were included. At the same time, only studies that had a cross-sectional or longitudinal design were chosen. In the case of the longitudinal ones, when the effect sizes were reported, only those presented after the first evaluation of the variables of interest were included in the analysis.A series of criteria were applied in order for studies to be considered eligible for inclusion in the meta-analysis. Thus, in terms of personality variable proposed the inclusion of studies that operationalized this construct by referring to personality traits from different theories , traits recently investigated in the literature in the field  and personality traits not associated with a particular theory . Thus, studies that used instruments that measured personality or previously mentioned close concepts were considered eligible.The eligibility criterion used in the case of the interest in undergoing an esthetic operation, studies that used instruments that measured the following constructs were considered eligible: interest in/likelihood of undergoing an esthetic operation, acceptance of esthetic operations, consideration of cosmetic surgery.With regard to the variable participants, they needed not to have had any previous cosmetic surgery and not to have bene diagnosed with a personality disorder. An age criterion was not included, as this phenomenon can also occur among adolescents, so the studies selected reported on participants of all age groups.As for the eligibility criteria associated with The identification of research that met the eligibility criteria was carried out with the help of electronic searches in the following databases: ScienceDirect, PsycInfo, Web of Science, Scopus, Springer and PubMed. The following search algorithm was applied to the abstracts, titles and keywords: (“cosmetic surgery” OR “consideration of cosmetic surgery” OR “acceptance of cosmetic surgery” OR “interest in cosmetic surgery”) AND . The studies chosen had all been published in English and subjected to a peer-review process. There was no specific time frame for the inclusion of studies; consideration was given to all studies published up until April 2023. The electronic search was complemented by a manual search, taking into account the references in the systematic reviews elaborated on topics of interest similar to that of the present meta-analysis. All articles identified were put into a list, from which the selection process was carried out.One thousand eight hundred sixty-nine studies were identified from the electronic database search, and 5 five additional studies were picked out using the manual search based on information provided by the systematic reviews of To perform the meta-analytic statistical analysis, the necessary data were extracted from each study included in the final meta-analysis (correlation coefficient and number of participants). Information was also extracted regarding the objectives of the studies, the main tools used, the characteristics of the participants and the results obtained.r) was reported. The Pearson correlation coefficient was measured within the relationships between personality, operationalized in all its previously mentioned forms, and interest in undergoing an esthetic operation. As a statistical approach, a random effects meta-analytic model was proposed, because there is a fairly wide variation among studies both in terms of their methodology for evaluating variables  and also with regard to the characteristics of the participants . Despite this, r, resorts to the transformation of the coefficient into Fischer’s z in order to perform the meta-analytical calculation; after the calculating operation, the result obtained is returned to its initial form . This process occurs because when we use Fischer’s z the dispersion of each effect size index depends exclusively on sample size, whereas when we use r it is interdependent with both sample size and correlation size. At the same time, if we are talking about empirical studies, we can see that the sample size is represented by the number of participants (N). If we are talking about the meta-analytic approach, the sample size is given by the number of studies included (k), so that in this meta-analysis the assessment of inter-study heterogeneity was calculated using the I2 index. Attempts were made to apply meta-regressions to investigate the moderating nature of various variables, but the small number of studies did not allow this analysis.The meta-analysis was performed using the Comprehensive Meta-Analysis program, version 4 . With reEgger’s intercept  was calcRegarding the relationship between personality traits and readiness to undergo cosmetic surgery, If we focus on the appearance-based rejection sensitivity personality trait , p > 0.05, p = 0.808 (I2 = 2.817), p > 0.05, p = 0.39, so there are no wide variations from one study to another. Regarding publication bias . Thus, according to the results obtained, the hypothesis is not statistically supported.Regarding  = 0.808 . In thision bias , Egger’sconscientiousness, 5 relationships were extracted from 3 eligible studies (ones that measured both constructs in accordance with the eligibility criteria). The analysis revealed a statistically insignificant r correlation coefficient, with a value of 0.106 , p > 0.05, p = 0.10 (2I shows a marked heterogeneity in effect sizes (I2 = 88.818), p < 0.01. This wide variation is most likely due to the small number of studies, but also to their characteristics . Regarding publication bias (p = 0.57). Thus, according to the results obtained, the hypothesis is not statistically supported.For p = 0.10 . Calculaion bias , Egger’sopenness, 7 relationships between the two constructs of interest were extracted from 4 eligible studies. The analysis revealed a statistically insignificant correlation coefficient r, with a value of 0.131 , p > 0.05, p = 0.13 (2I = 96.950), p < 0.01, this wide variation being most likely due to the small number of studies, but also to their characteristics . Regarding publication bias, Egger’s t test was not statistically significant  (For p = 0.13 . However = 0.57) . In thislow neuroticism  4 relationships were extracted from two eligible studies , p > 0.05, p = 0.76 (I2 = 86.845), p < 0.01, this wide variation being most likely due to the small number of studies, but also to their characteristics . Regarding publication bias, Egger’s t test was not statistically significant  (Turning to p = 0.76 . In this = 0.24) . In thisk = 2 for each of the two traits). Referring to narcissism, 3 relationships were extracted from the 2 eligible studies. The analysis revealed a statistically insignificant r correlation coefficient, with a value of 0.052 , p > 0.05, p = 0.23 (I2 = 0.000), p > 0.05, p = 0.86, so there are no wide variations from one study to another. Regarding publication bias, Egger’s t-test was not statistically significant   . In thisr was recorded, with a value of 0.270 , p < 0.01 (I2 = 14.846), p > 0.05, p = 0.31, so there are no wide variations from one study to another. Regarding publication bias, Egger’s t-test was not statistically significant   . The hypself-oriented perfectionism, other-oriented perfectionism, and socially prescribed perfectionism. The same authors later focused on a new feature related to perfectionism, namely perfectionistic self-presentation, which in its turn is formed of three stable dimensions: perfectionistic self-promotion, non-disclosure of imperfection, and non-display of imperfection , p < 0.05, p = 0.01, this wide variation being most likely due to the small number of studies, but also to their characteristics . Regarding publication bias (p = 0.09). Thus, according to the results obtained, the hypothesis is statistically supported.Taking p = 0.02 . In thision bias , Egger’sself-oriented perfectionism, 4 relationships between the two constructs of interest were extracted from 1 eligible study. The analysis revealed a statistically insignificant correlation coefficient r, with a value of 0.020 , p > 0.05, p = 0.77 (I2 = 59.411), p > 0.05, p = 0.06, so there are no wide variations from one study to another. Regarding publication bias, Egger’s t-test was not statistically significant  (For p = 0.77 . Followi = 0.70) . In thissocially prescribed perfectionism, 4 relationships between the two constructs of interest were extracted from 1 eligible study. The analysis revealed a statistically significant correlation coefficient r, with a value of 0.188 , p < 0.05, p = 0.01 (I2 = 65.527), p < 0.05, p = 0.03, this wide variation being most likely due to the small number of studies, but also to their characteristics . Regarding publication bias (p = 0.40). Thus, according to the results obtained, the hypothesis is statistically supported.For p = 0.01 . In thision bias , Egger’snon-disclosure of imperfection, non-display of imperfection, and other-oriented perfectionism a meta-analytic approach could not be taken here, as there were no enough studies on these topics. Also, regarding perfectionism only one study conceptualized this variable as a single trait without any dimensions  were also introduced into the analysis. Both participant characteristics and research design characteristics were quite varied. The subjects of the studies ranged from teenagers to young adults to adults aged 35–55. In terms of design characteristics, a wide diversity of research instruments was observed . It was observed that the highest number of studies investigated were carried out in the USA, UK and Iran, followed by Norway, Germany, the UAE and Canada. Regarding the statistical analyses used in the studies that qualified for the meta-analysis, most of them used advanced techniques in order to better understand the relationship between the variables measured, as well as to discover other variables that might somehow predict or mediate this association between variables.Following the analyses carried out, the researchers’ expectations were partially supported by the results, proving the existence of a significant relationship between perfectionism  and appearance-based rejection sensitivity and interest in undergoing an esthetic operation. There were no significant relationships between openness, emotional stability, extraversion, agreeableness, conscientiousness narcissism or self-oriented perfectionism and acceptance of cosmetic surgery. For Machiavellianism, psychopathy, introversion, neuroticism, non-display of imperfection, non-disclosure of imperfection, other oriented perfectionism, statistical analysis could not be performed because there were insufficient eligible studies for us to be able to study the relationship between them and the desire to undergo cosmetic surgery.According to our meta-analysis, a person who wants to undergo cosmetic surgery may also have high levels of perfectionism  and attitudes toward cosmetic surgery . There wThe results of the meta-analysis show the role that certain personality traits can play in a person’s decision to undergo cosmetic surgery. When someone possesses these traits, their predisposition to internalize messages from the three sources of influence regarding culturally imposed standards and to engage in self-objectification once the messages have been accepted can be much greater. As observed in the specialist literature, this process can lead to dissatisfaction related to body image , with the result that eating disorders and various body modification strategies may appear, one of which is resorting to esthetic operations. In addition to this, It is therefore vital to design interventions that highlight the risks that accompany the decision to undergo an esthetic operation. While the studies investigated in the analysis partially confirmed the researchers’ expectations, the results must be interpreted with great caution, since the relatively small number of studies means that it is not possible to draw general conclusions from them; this represents a first limitation. This paucity of relevant studies may be because the field of cosmetic surgery in relation to personality traits in the non-clinical population is such a new one that few researchers have yet looked at the relationships between these variables. By contrast, the relationship between body image and interest in cosmetic surgery has been studied much more comprehensively.Another limitation could be the fact that one of the eligibility criteria required studies to have been subjected to a peer-review process, so there is a possibility that relevant dissertations and other unpublished research work will have been omitted from the meta-analysis.A further limitation could be the fact that not all the studies measured all the targeted constructs with the help of standardized instruments (there are relatively few instruments that measure esthetic surgery constructs that could be associated with variables of interest), which suggests there is a need to carry out work to design and validate such instruments in as many countries as possible.A final limitation is the fact that not all the variables were operationalized in the same way. What is needed is a specific theoretical model for this topic that will include all the factors that can influence a person’s decision to undergo cosmetic surgery.Interest in cosmetic surgery has grown enormously in recent times. People want to feel good about their bodies and to achieve their ideal of beauty, but sometimes this desire is so strong that the risks that accompany making such a decision are no longer taken into account. Cosmetic surgeons should familiarize themselves with their patients’ personality traits and characteristics before modifying body parts, precisely in order to prevent any adverse results. disorder guidelines to rely on. The present meta-analysis highlights the need for psychologists and psychotherapists to develop guidelines giving productive behaviors and approaches for cosmetic surgeons to adopt when people from the non-clinical population who have different personality traits walk into their offices requesting esthetic surgery.It goes without saying that some of the personality traits investigated in this meta-analysis may be associated with certain behaviors specific to personality disorders. It is important that esthetic surgeons and psychotherapists should know what approach to adopt with clients when working with them regarding their desire to undergo cosmetic surgery. However, the current situation is that cosmetic surgeons in this position have only personality The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.MV and G-ML: conceptualization, methodology of the study, and data analysis. G-ML: data collection, data proofing, and manuscript writing. MV: manuscript review. All authors contributed to the article and approved the submitted version.Open access publication fees received from West University of Timisoara.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. 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Against the backdrop of considerable lack of research, this study provides the first exploration of medical students’ perspectives on racism in medicine and healthcare in Germany. The aim is to identify problems and learning needs for medical education. We address the following research questions: – How do medical students perceive racism in medicine and healthcare in Germany? – How do they address, understand, and discuss different aspects of racism in this context? – What are their expectations regarding the role of medical education?Semi-structured online focus group discussions were conducted with 32 medical students from 13 different medical schools in Germany. The discussions were transcribed and analyzed using qualitative content analysis. Based on the analysis of the focus groups, four main hypotheses could be formulated: 1. Medical students perceive racism in medicine and healthcare in Germany as a ubiquitous phenomenon. 2. They have problems to identify racist behaviour and structures due to conceptual knowledge gaps. 3. They are insecure how to deal with racism on a situational level. 4. They hold medical education accountable to tackle racism in medicine and healthcare on various levels.Our study raises specific learning needs for addressing racism in medicine and healthcare in Germany. Research from the US-context might inspire innovative approaches for German medical education but needs to take national specificities into account. Further research is needed to prepare the implementation of antiracist training in German medical education. National Competence Based Catalogue of Learning Objectives for Undergraduate Medical Education (NKLM) [https://www.nklm.de], racism is explicitly addressed as a relevant topic of German medical education for the first time  [https://nklm.de/zend/objective/view/id/10001324/essential/yes/lve/211449]. This marks the acknowledgment of a long-standing desideratum in Germany. The rejection of any form of discrimination constitutes an important precept of medical ethics articulated in prominent professional codices, such as the World Medical Association's Geneva Declaration. Moreover, at the national level, the German General Act on Equal Treatment (AGG) also applies to racist discrimination in the healthcare system ..NationalEspecially within the Anglo-American discussion, there has been a surge of research and strategic actions addressing racism, discrimination, and structural disparities in medicine and healthcare in recent years , 8]. By. By8]. BAgainst this backdrop, our study provides the first exploration of medical students’ awareness of racism in medicine and healthcare in Germany. Guided by Kern’s six step approach of curriculum development , we idenHow do medical students perceive racism in medicine and healthcare in Germany? How do they address, understand, and discuss different aspects of racism in this context? What are their expectations regarding the role of medical education? To answer these questions, we conducted online focus groups with students from medical schools all over Germany. The discussions covered aspects of interpersonal, institutional, and structural racism as well as demands for medical education to address these topics. The data were analyzed with qualitative content analysis.Given the lack of previous research on this topic, we developed an explorative qualitative study. To elucidate medical students’ awareness and understanding of racism in medicine and healthcare, we conducted several moderated online focus group discussions with four to seven participants. This method appeared particularly suitable to elicit a range of different positions and arguments. The recruitment of participants took place between June and August 2021. Public calls for participation were disseminated via local student bodies, offices of student affairs, lecturers, informal student groups, and social media. We used a snowball sampling method. A pre-questionnaire was distributed to collect socio-demographic information . The composition of the sample was aimed to be as diverse as possible regarding gender, study year, sociocultural background, and geographical location. Inclusion criteria were legal age, sufficient proficiency in the German language, and enrolment in medicine at a university in Germany. Participants provided written informed consent in advance. Institutional review board approval was obtained from the ethics committee of the Medical Faculty of the University of Oldenburg (No. 2021-080).Altogether, six focus group discussions with 32 participants took place between July and September 2021. The participants came from 13 different medical schools across Germany . Racism is a common experience for racialized healthcare practitioners and students. For example, they describe being perceived as less competent, not as a doctor , or being referred to as “unclean” and carriers of infectious diseases . Some patients refused to be examined by them . The combination of subtle everyday experiences of racism and explicit racist aggressions, such as somebody who “throws a T-shirt at me and says, well, my T-shirt comes from where you come from”  are seen as troubling and impeding the affected students’ focus and learning experience: “that’s just fucking exhausting to sit there all the time and justify your existence” .Throughout all the conducted focus groups, medical students report racism in interindividual interactions within healthcare and medical education, irrespectively of different medical specialties. While racist discrimination from healthcare workers against patients is perceived as particularly problematic, experiences of racism are reported across all groups in medicine, healthcare, and education, such as patients, doctors, nurses, lecturers, and students. One student who identifies as a person of colour in the discussion explains: Racism is also reported in context of institutional and structural conditions. In medical schools, students remember racist knowledge and stereotypes that are imparted from academic and clinical teaching. They criticize lecturers’ lack of sensitivity for, and the uncritical use of, racist stereotypes and categorizations:“the lecturer had projected a small comic on the wall, where […] somehow a room was to be seen. A turban wearing man with a long beard and a bomb belt came in, shouted Allahu Akbar and uh the people sitting in there said “bless you”. And so that was the joke.” “wide off the mark” and to “serve racist stereotypes” .Only after a Muslim student drew attention to the problematic content, other students evaluated the comic as “these teaching materials are very problematic and discriminating […]. Always for the disgusting diseases it’s racialized people” . Moreover, students criticize the use of racial categorizations in books, lectures, and medical guidelines for falsely implying biological differences between races. One participant claims that when these categorizations come up in lectures for example, in health data from the US-context, they are often not sufficiently contextualized . At the same time, students identify institutional racism in what is not taught, for example in the context of teaching common diseases on darker skin in dermatology: “classic children's diseases […] mumps, measles, rubella, cyanosis are not shown in the textbooks with black people” . Students find this knowledge gap problematic as it may impede the quality of healthcare for patients with darker skin . Also, the teaching material is subject to criticism. One student remembers that  “everyone defines racism differently or sees the boundaries differently” . Furthermore, some participants have difficulties to differentiate between racism and professional medical reasoning and behaviour. For example, there is intensive discussion about the legitimacy of the term “Morbus Mediterraneus” . While some find its use “super racist” , others understand it as “very practical”  because “ultimately this is also very important for us in medicine, of course within a certain limit, […] to classify people and to think in rough pigeonholes. In the end, there's no other way to do it” . Racial categorizations are therefore not understood as “per se” racist by some students as it is “about medical conditions, somehow to represent and to be able to measure certain things” .Although the participants report many pertinent experiences, the definite assessment of the range of racism in medicine and healthcare poses a challenge. The medical students lack the theoretical knowledge to define racism since“I hope that they are not treated badly due to their skin colour. […] but that it [the unequal treatment] is based on the socio-economic status” . While healthcare disparities between different patient groups are acknowledged, racism is not seen as the root cause, but rather substituted for other categories like class.Medical students find it difficult to identify structural racism. While it is easier for them to identify racism on the individual level, the understanding of structural racism in the German context poses a significant challenge. Confronted with examples of structural racism in the US-context during the focus groups, students can identify structural disparities but repeatedly speculate to what extent the true reason for health disparities is a matter of lifestyle . When discussing similar phenomena in the German context, they tend to play down the effect of structural racism on health compared to other factors, such as socioeconomic status or educational background. One student with no personal experience of racist discrimination reasons: “In that situation I actually didn't really know how to react there because the atmosphere is so a bit loose and yeah, somehow was a bit weird” . Despite evaluating the remark as racist, the perceived “loose” atmosphere made her question her own experience and finally prevented her speaking up. Humour is named as a prominent disguise of racist situations and causes insecurities about how to respond . Additionally, the pronounced hierarchical power structures in the medical context are addressed as a factor why medical students do not speak up when faced with racist discrimination: When discussing racism in medicine, students with and without own experiences with racism often verbalize insecurities about how to react in any given situation or handle racism in general. Situational and institutional factors are named as possible causes. A first-year student experienced an anti-Asian remark from a general practitioner in an internship and reflects on her lack of reaction: “because you are at the bottom of the food chain anyway […]. And then you usually prefer to think 'I'll accept it now' or 'I'll just look now, I'll look past it', instead of thinking that it really is a racist attack.”  “If you then go to colleagues and they say, 'oh come on, it's not meant like that'. Then you feel somehow totally invalid”.  Students describe it as a “taboo”  to name racism which results in a “culture of silence” . In the context of academic teaching, they fear consequences when criticizing lecturers. One student describes the intimidating response of a physiology lecturer after calling out racist content in a lecture as “a very, very nasty e-mail” . As a result, the student preferred not to continue her studies in the same semester as she did not see any other way to avoid being examined by that lecturer . Against the backdrop of such experiences, students call for public institutional contact and counselling points for those who experience racism in medical education .In this context, sharing experiences with racism might be associated with feelings of vulnerability and insecurity and/or are met with disbelief:“but we didn't talk about racism at all […] in the official curriculum” . Yet, the modalities and contents of antiracism in medical education are discussed controversially. Regarding the modalities, medical students discuss whether classes on racism in medicine should be mandatory or optional. While some see racism as a general societal problem that does not have to be covered in the medical curriculum , others recommend mandatory classes: “design the courses in such a way that you are forced to deal with it […] just to create a basic awareness” . While certain subject areas such as “medical sociology and psychology” , “medical ethics” , or “communication training”  are seen as being particularly responsible to address issues of racism, medical students emphasize that critical approaches to racism should not only form a part of academic teaching. The effectiveness of university medical education is called into question given the power of the “hidden curriculum”  and “that these categories and prejudices […] are passed on from generation to generation” . Therefore, medical students stress the need to include critical education on racism in clinical practice and highlight the importance of role models . However, they criticize a general lack of expertise on racism in medicine and healthcare in the faculty staff at medical schools in Germany .The participants unanimously agree that racism in medicine should be made an explicit topic of medical education as it is currently mostly neglected: “integrated into medical studies, that one talks about how one deals with one’s own racism, how one recognizes it, how one averts it” . In addition, they suggest training that equips them with the necessary skills to react and deal with racist situations in clinical practice: “how one also reacts to racist situations, with the staff, but also with patients” . Finally, students call upon universities to promote a more diverse student and staff body, because “representation matters”  and medical students and physicians in Germany are perceived as “very white, very privileged” .Regarding the content of antiracist medical education on the one hand, students ask for teaching of specific knowledge, e.g., about the effects of racism on health , dermatology on darker skin  or the role of academic medicine during racist crimes in the context of German colonialism . On the other hand, they demand possibilities for self-reflection to develop a critical professional attitude towards racism. It was suggested that this latter point be Our results show that medical students discuss racism as a ubiquitous phenomenon in medicine and healthcare. Racism can appear in all medical specialties and interpersonal interactions. They also highlight the difficulties of medical students to identify and evaluate racism, especially at a structural level. Furthermore, students are uncertain how to deal with racism, either when it is experienced or witnessed. They also complain about a lack of anti-discriminatory structures in medical institutions. Finally, our participants see it as the responsibility of medical education to tackle racism in medicine and healthcare.Our findings show similarities with international studies, e.g., regarding the ubiquity of racism in medicine  or the sIn fact, a multitude of recommendations and evaluations of antiracist curricular interventions have been published in the Anglo-American literature , 23], , , 25], , , 27], , , 29], , . HoweverOur study is not exhaustive. Although we included students from all phases of medical studies and a great variety of different medical faculties in Germany, our overall sample is comparatively small. Furthermore, around one third of the participants had been interested in racism in medicine beforehand or were engaged in political activism or had prior knowledge. Further systematic quantitative research is necessary to develop a more nuanced and representative picture. Due to the multiprofessional nature of the healthcare system, the role of racism needs to be studied from the perspectives of other healthcare professions as well. The focus group method might also have influenced the way racism was addressed e.g., by social desirability effects. Finally, it must be stated that our social position as medical ethicists with no personal experience of racism may have also influenced our research perspective , 38]..38].https://nklm.de/zend/objective/view/id/10001324/essential/yes/lve/211449]. Yet, they also show that didactic approaches are not enough. Ultimately, medical schools also need to address racism comprehensively at an institutional and structural level to foster substantial change. Nevertheless, our findings allow us to draw several conclusions concerning antiracist medical education. The perceived ubiquity of racism in medicine and healthcare implies the necessity to foster antiracist action in a comprehensive way, including changes in both academic and clinical settings on individual and institutional levels. As medical students present difficulties in identifying and discussing racism, there is a need for antiracist education in the academic and clinical settings as well as in their own professional development. This is especially noted with their perceived difficulty to identify structural racism, which suggests the need for teaching on the social determinants of health and the role of structural racist discrimination. The appropriate integration of such aspects into the curricula should also be reflected at the level of quality assurance in medicals education, but also in other health professions . ). 40]). We would like to thank Shagana Shanmuganathan and Silke Schicktanz (UMG) for their support in the conception of the study, Houda Hallal (Köln) for her helpful comments on the manuscript. For the exchange on content and methods we thank Tanja Gangarova, Felicia Boma Lazaridou and Hans Vogt (DeZIM). Many thanks to Lucas Rateitschak for his help in the transcription process and to Cai Weaver for his linguistic editing. The authors declare that they have no competing interests.