Commentary: Racism and Bias in Health Professions Education: How Educators, Faculty Developers, and Researchers Can Make a Difference

A Conceptual Framework for Exploring the Experiences of Underrepresented Racial Minorities in Pharmacy School

Objective. To explore the social and academic experiences of students identifying as underrepresented racial minorities (URMs) in a pharmacy school, how they made meaning of their experiences, and the strategic actions they took to navigate towards degree completion. Methods. Twenty students from a school of pharmacy within a research-intensive institution participated in semi-structured interviews. Data were analyzed through several rounds of coding. Trustworthiness procedures included the use of multiple coders, a dependability audit, and analytic memos to promote reflexivity. Results. The study yields a conceptual model. Pre-pharmacy school factors such as pipeline programs, work experiences, family, and URM health professionals impacted students' interest in and encouragement to attend pharmacy school. Students reported experiences including a lack of diversity, feeling unwelcomed, and concerns about cultural competency and group work challenges. Students were motivated by URM faculty members, self-efficacy, and a sense of purpose. Students were inhibited by the mental impact of sociopolitical events, the pressures of representing their race/ethnicity, and feeling inferior. Students took several actions to navigate the school including "code-switching," finding solace and support with other URMs, seeking cultural competence-related experiences to complement the curriculum, and strategically remaining silent or speaking up during group work conflicts. Conclusion. This exploratory study provides a roadmap to better understand URM students' journey to pharmacy school and experiences therein. Findings could be used by pharmacy schools to create a more inclusive environment for URM students and provide future directions for scholars pursing diversity-related research agendas in health professions education.

Health Equity Rounds: An Interdisciplinary Case Conference to Address Implicit Bias and Structural Racism for Faculty and Trainees

INTRODUCTION

The medical community recognizes the importance of confronting structural racism and implicit bias to address health inequities. Several curricula aimed at teaching trainees about these issues are described in the literature. However, few curricula exist that engage faculty members as learners rather than teachers of these topics or target interdisciplinary audiences.

METHODS

We developed a longitudinal case conference curriculum called Health Equity Rounds (HER) to discuss and address the impact of structural racism and implicit bias on patient care. The curriculum engaged participants across training levels and disciplines on these topics utilizing case-based discussion, evidence-based exercises, and two relevant conceptual frameworks. It was delivered quarterly as part of a departmental case conference series. We evaluated HER's feasibility and acceptability by tracking conference attendance and administering postconference surveys. We analyzed quantitative survey data using descriptive statistics and qualitatively reviewed free-text comments.

RESULTS

We delivered seven 1-hour HER conferences at our institution from June 2016 to June 2018. A mean of 66 participants attended each HER. Most survey respondents (88% or more) indicated that HER promoted personal reflection on implicit bias, and 75% or more indicated that HER would impact their clinical practice.

DISCUSSION

HER provided a unique forum for practitioners across training levels to address structural racism and implicit bias. Our aim in dissemination is to provide meaningful tools for others to adapt at their own institutions, recognizing that HER should serve as a component of larger, multifaceted efforts to decrease structural racism and implicit bias in health care.

The Implicit Association Test in health professions education: A meta-narrative review

INTRODUCTION

Implicit bias is a growing area of interest among educators. Educational strategies used to elicit awareness of implicit biases commonly include the Implicit Association Test (IAT). Although the topic of implicit bias is gaining increased attention, emerging critique of the IAT suggests the need to subject its use to greater theoretical and empirical scrutiny.

METHODS

The authors employed a meta-narrative synthesis to review existing research on the use of the IAT in health professions education. Four databases were searched using key terms yielding 1151 titles. After title, abstract and full-text screening, 38 articles were chosen for inclusion. Coding and analysis of articles sought a meaningful synthesis of educational approaches relating to the IAT, and the assumptions and theoretical positions that informed these approaches.

RESULTS

Distinct, yet complementary, meta-narratives were found in the literature. The dominant perspective utilizes the IAT as a metric of implicit bias to evaluate the success of an educational activity. A contrasting narrative describes the IAT as a tool to promote awareness while triggering discussion and reflection.

DISCUSSION

Whether used as a tool to measure bias, raise awareness or trigger reflection, the use of the IAT provokes tension between distinct meta-narratives, posing a challenge to educators. Curriculum designers should consider the premise behind the IAT before using it, and be prepared to address potential reactions from learners such as defensiveness or criticism. Overall, findings suggest that educational approaches regarding implicit bias require critical reflexivity regarding assumptions, values and theoretical positioning related to the IAT.

The Effects of Racism in Medical Education on Students' Decisions to Practice in Underserved or Minority Communities

PURPOSE

The purpose of this study was to examine the relationship between manifestations of racism in medical school and subsequent changes in graduating medical students' intentions to practice in underserved or minority communities, compared with their attitudes and intentions at matriculation.

METHOD

The authors used repeated-measures data from a longitudinal study of 3,756 students at 49 U.S. medical schools that were collected from 2010 to 2014. They conducted generalized linear mixed models to estimate whether manifestations of racism in school curricula/policies, school culture/climate, or student attitudes/behaviors predicted first- to fourth-year changes in students' intentions to practice in underserved communities or primarily with minority populations. Analyses were stratified by students' practice intentions (no/undecided/yes) at matriculation.

RESULTS

Students' more negative explicit racial attitudes were associated with decreased intention to practice with underserved or minority populations at graduation. Service learning experiences and a curriculum focused on improving minority health were associated with increased intention to practice in underserved communities. A curriculum focused on minority health/disparities, students' perceived skill at developing relationships with minority patients, the proportion of minority students at the school, and the perception of a tense interracial environment were all associated with increased intention to care for minority patients.

CONCLUSIONS

This study provides evidence that racism manifested at multiple levels in medical schools was associated with graduating students' decisions to provide care in high-need communities. Strategies to identify and eliminate structural racism and its manifestations in medical school are needed.

Defining a framework for medical teachers' competencies to teach ethnic and cultural diversity: Results of a European Delphi study

BACKGROUND

Medical students need to be trained in delivering diversity-responsive health care but unknown is what competencies teachers need. The aim of this study was to devise a framework of competencies for diversity teaching.

METHODS

An open-ended questionnaire about essential diversity teaching competencies was sent to a panel. This resulted in a list of 74 teaching competencies, which was sent in a second round to the panel for rating. The final framework of competencies was approved by the panel.

RESULTS

Thirty-four experts participated. The final framework consisted of 10 competencies that were seen as essential for all medical teachers: (1) ability to critically reflect on own values and beliefs; (2) ability to communicate about individuals in a nondiscriminatory, nonstereotyping way; (3) empathy for patients regardless of ethnicity, race or nationality; (4) awareness of intersectionality; (5) awareness of own ethnic and cultural background; (6) knowledge of ethnic and social determinants of physical and mental health of migrants; (7) ability to reflect with students on the social or cultural context of the patient relevant to the medical encounter; (8) awareness that teachers are role models in the way they talk about patients from different ethnic, cultural and social backgrounds; (9) empathy for students of diverse ethnic, cultural and social background; (10) ability to engage, motivate and let all students participate.

CONCLUSIONS

This framework of teaching competencies can be used in faculty development programs to adequately train all medical teachers.

How to Make or Break Implicit Bias Instruction: Implications for Curriculum Development

PURPOSE

To analyze faculty experiences regarding facilitating discussions as part of the institution's curriculum on racial and ethnic implicit bias recognition and management.

METHOD

Between July 2014 and September 2016, the authors conducted 21 in-depth interviews with faculty who had experience teaching in implicit bias instruction or were interested in facilitating discussions related to implicit bias and the Implicit Association Test. Grounded theory methodology was used to analyze interview transcripts.

RESULTS

Participants identified challenges that affect their ability to facilitate instruction in implicit bias. Faculty described the influence of their own background and identities as well as the influence of institutional values on their ability to facilitate implicit bias discussions. They noted the impact of resistant learners and faculty during discussions and made suggestions for institutional measures including the need for implementation of formalized longitudinal implicit bias curricula and faculty development.

CONCLUSIONS

Faculty facilitating sessions on implicit bias must attend faculty development sessions to be equipped to deal with some of the challenges they may face. Buy-in from institutional leadership is essential for successful implementation of implicit bias teaching, and medical educators need to consider formalized longitudinal curricula addressing the recognition and management of implicit biases.