Implicit Bias in Health Professions: From Recognition to Transformation

Implicit Bias Training in Health Professions Education: A Scoping Review

There is a recurrent call for effective implicit bias (IB) education within health professions education (HPE). We aimed to explore the state of IB education within HPE for clinical learners and IB educators using the Arksey and O'Malley scoping review framework. Thirty publications variable in curricular design met inclusion criteria. No studies assessed learner outcomes at the level of Miller's "shows" or "does" nor reported program evaluation outcomes at the level of Kirkpatrick's "behavior" or "results." Rigorous, theory-guided studies assessing behavioral change, patient care delivery, and patient outcomes are needed to move the field of IB education forward within HPE.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-022-01673-z.

Blind spots in medical education: how can we envision new possibilities?

As human beings, we all have blind spots. Most obvious are our visual blind spots, such as where the optic nerve meets the retina and our inability to see behind us. It can be more difficult to acknowledge our other types of blind spots, like unexamined beliefs, assumptions, or biases. While each individual has blind spots, groups can share blind spots that limit change and innovation or even systematically disadvantage certain other groups. In this article, we provide a definition of blind spots in medical education, and offer examples, including unfamiliarity with the evidence and theory informing medical education, lack of evidence supporting well-accepted and influential practices, significant absences in our scholarly literature, and the failure to engage patients in curriculum development and reform. We argue that actively helping each other see blind spots may allow us to avoid pitfalls and take advantage of new opportunities for advancing medical education scholarship and practice. When we expand our collective field of vision, we can also envision more "adjacent possibilities," future states near enough to be considered but not so distant as to be unimaginable. For medical education to attend to its blind spots, there needs to be increased participation among all stakeholders and a commitment to acknowledging blind spots even when that may cause discomfort. Ultimately, the better we can see blind spots and imagine new possibilities, the more we will be able to adapt, innovate, and reform medical education to prepare and sustain a physician workforce that serves society's needs.

The Presence 5 for Racial Justice Framework for anti-racist communication with Black patients

OBJECTIVE

To identify communication practices that clinicians can use to address racism faced by Black patients, build trusting relationships, and empower Black individuals in clinical care.

DATA SOURCES

Qualitative data (N = 112 participants, August 2020-March 2021) collected in partnership with clinics primarily serving Black patients in Leeds, AL; Memphis, TN; Oakland, CA; and Rochester, NY.

STUDY DESIGN

This multi-phased project was informed by human-centered design thinking and community-based participatory research principles. We mapped emergent communication and trust-building strategies to domains from the Presence 5 framework for fostering meaningful connection in clinical care.

DATA COLLECTION METHODS

Interviews and focus group discussions explored anti-racist communication and patient-clinician trust (n = 36 Black patients; n = 40 nonmedical professionals; and n = 24 clinicians of various races and ethnicities). The Presence 5 Virtual National Community Advisory Board guided analysis interpretation.

PRINCIPAL FINDINGS

The emergent Presence 5 for Racial Justice (P5RJ) practices include: (1) Prepare with intention by reflecting on identity, bias, and power dynamics; and creating structures to address bias and structural determinants of health; (2) Listen intently and completely without interruption and listen deeply for the potential impact of anti-Black racism on patient health and interactions with health care; (3) Agree on what matters most by having explicit conversations about patient goals, treatment comfort and consent, and referral planning; (4) Connect with the patient's story, acknowledging socioeconomic factors influencing patient health and focusing on positive efforts; (5) Explore emotional cues by noticing and naming patient emotions, and considering how experiences with racism might influence emotions.

CONCLUSION

P5RJ provides a framework with actionable communication practices to address pervasive racism experienced by Black patients. Effective implementation necessitates clinician self-reflection, personal commitment, and institutional support that offers time and resources to elicit a patient's story and to address patient needs.

Brief online implicit bias education increases bias awareness among clinical teaching faculty

PROBLEM AND PURPOSE

Healthcare provider implicit bias influences the learning environment and patient care. Bias awareness is one of the key elements to be included in implicit bias education. Research on education enhancing bias awareness is limited. Bias awareness can motivate behavior change. The objective was to evaluate whether exposure to a brief online course, Implicit Bias in the Clinical and Learning Environment, increased bias awareness.

MATERIALS AND METHODS

The course included the history of racism in medicine, social determinants of health, implicit bias in healthcare, and strategies to reduce the impact of implicit bias in clinical care and teaching. A sample of U.S. academic family, internal, and emergency medicine providers were recruited into the study from August to December 2019. Measures of provider implicit and explicit bias, personal and practice characteristics, and pre-post-bias awareness measures were collected.

RESULTS

Of 111 participants, 78 (70%) were female, 81 (73%) were White, and 63 (57%) were MDs. Providers held moderate implicit pro-White bias on the Race IAT (Cohen's d = 0.68) and strong implicit stereotypes associating males rather than females with 'career' on the Gender-Career IAT (Cohen's d = 1.15). Overall, providers held no explicit race bias (Cohen's d = 0.05). Providers reported moderate explicit male-career (Cohen's d = 0.68) and strong female-family stereotype (Cohen's d = 0.83). A statistically significant increase in bias awareness was found after exposure to the course (p = 0.03). Provider implicit and explicit biases and personal and practice characteristics were not associated with an increase in bias awareness.

CONCLUSIONS

Implicit bias education is effective to increase providers' bias awareness regardless of strength of their implicit and explicit biases and personal and practice characteristics. Increasing bias awareness is one step of many toward creating a positive learning environment and a system of more equitable healthcare.

Maybe they had a bad day: how LGBTQ and BIPOC patients react to bias in healthcare and struggle to speak out

OBJECTIVE

People who experience marginalization, including Black, Indigenous, People of Color (BIPOC) and Lesbian, Gay, Bisexual, Transgender, Queer, Plus (ie, all other marginalized genders and sexual orientations) people (LGBTQ+) experience discrimination during healthcare interactions, which negatively impacts patient-provider communication and care. Yet, scarce research examines the lived experience of unfair treatment among patients from marginalized groups to guide patient-centered tools that improve healthcare equity.

MATERIALS AND METHODS

We interviewed 25 BIPOC and/or LGBTQ+ people about their experiences of unfair treatment and discrimination when visiting healthcare providers. Through thematic analysis, we describe participants' immediate reactions and longer-term consequences of those experiences.

RESULTS

We identified 4 ways that participants reacted to discrimination in the moment: Fighting, Fleeing, Excusing, and Working Around Bias. Long-term consequences reflect 6 ways they coped: Delaying or Avoiding Care, Changing Healthcare Providers, Self-prescribing, Covering Behaviors, Experiencing Health Complications, and Mistrusting Healthcare Institutions.

DISCUSSION

By describing how patients react to experiences of unfair treatment and discrimination, our findings enhance the understanding of health disparities as patients cope and struggle to speak out.To combat these problems, we identify 3 future directions for informatics interventions that improve provider behavior, support patient advocacy, and address power dynamics in healthcare.

CONCLUSIONS

BIPOC and LGBTQ+ patients' perspectives on navigating unfair treatment and discrimination in healthcare offers critical insight into their experiences and long-term consequences of those experiences. Understanding the circumstances and consequences of unfair treatment, discrimination, and the impact of bias through this patient-centered lens is crucial to inform informatics technologies that promote health equity.

Consensus on an implicit bias and health disparities curriculum in neonatal medicine: a Delphi study

OBJECTIVE

Despite longstanding and recurrent calls for effective implicit bias (IB) education in health professions education as one mechanism to reduce ongoing racism and health disparities, such curricula for neonatal-perinatal medicine (NPM) are limited. We aim to determine the key curricular elements for educating NPM fellows, advanced practice providers, and attending physicians in the critical topics of IB and health disparities.

STUDY DESIGN

A modified Delphi study was performed with content experts in IB and health disparities who had educational relationships to those working and training in the neonatal intensive care unit.

RESULT

Three Delphi rounds were conducted from May to November 2021. Experts reached consensus on a variety of items for inclusion in the curriculum, including educational goals, learning objectives, teaching strategies, and educator principles.

CONCLUSION

Essential curricular components of an IB and health disparities curriculum for neonatal medicine were defined using rigorous consensus building methodology.

The network science of collective intelligence

In the last few years, breakthroughs in computational and experimental techniques have produced several key discoveries in the science of networks and human collective intelligence. This review presents the latest scientific findings from two key fields of research: collective problem-solving and the wisdom of the crowd. I demonstrate the core theoretical tensions separating these research traditions and show how recent findings offer a new synthesis for understanding how network dynamics alter collective intelligence, both positively and negatively. I conclude by highlighting current theoretical problems at the forefront of research on networked collective intelligence, as well as vital public policy challenges that require new research efforts.

Confronting implicit bias toward patients: a scoping review of post-graduate physician curricula

BACKGROUND

Physicians' behavior may unknowingly be impacted by prejudice and thereby contribute to healthcare inequities. Despite increasingly robust data demonstrating physician implicit bias (The Office of Minority Health. Minority Population Profiles, 2021; COVID-19 Shines Light on Health Disparities, National Conference of State Legislatures 2021), the evidence behind how to change this with training programs remains unclear. This scoping review therefore reports on the implementation, outcomes, and characteristics of post-graduate physician implicit bias curricula.

METHODS

The authors conducted a literature review using scoping review methodology. They searched 7 databases in February and November 2020 for English-language academic and gray literature on implicit bias curricula for physicians at all levels of post-graduate training. Ten reviewers screened studies for eligibility independently, then extracted data from these studies and compiled it into a chart and analytical summary.

RESULTS

Of the 4,599 articles screened, this review identified 90 articles on implicit bias interventions for post-graduate physicians. Inductive data analysis revealed a spectrum of educational approaches, which were categorized int o 4 educational models called Competence, Skills-Based, Social Contact, and Critical Models. The most commonly reported strength was the interactive nature of the curricula (26%), and the most frequently identified challenges were related to time and resources available (53%). Half of the interventions discussed facilitator preparation, and the majority (62%) evaluated outcomes using pre and post self-assessments.

CONCLUSIONS

This review provides a comprehensive synthesis of the literature on physician implicit bias curricula. It is our goal that this supports medical educators in applying and improving aspects of these interventions in their own programs.

Critical reflection on required service to the community propels prospective medical students toward higher empathy, compassion, and bias mitigation but are these gains sustainable?

Purpose

We observed increased cognitive empathy and reflective capacity scores when prospective medical students wrote critical reflections on mandatory team service-learning in a Medical Humanities course, but these findings did not include a control group. Here we compare these survey results in similar courses with and without required service-learning.

Methods

Forty-three prospective medical students completed a Medical Humanities course requiring critical reflection on team service-learning. In comparison, 32 students finished a similar course in which service to the community was not mandatory. Before starting the courses, students completed reliable surveys of their cognitive empathy and reflective capacity, and more than 93% of the students completed the same surveys after finishing the courses.

Results

Students' cognitive empathy and reflective capacity scores increased significantly when service-learning was required, but the scores did not increase significantly when service to the community was not required. The effect size for the empathy increase was of crucial practical importance (r = 0.50), whereas it was of moderate practical importance for the increase in reflective capacity (r = 0.34).

Conclusions

These and prior findings strongly support the conclusion that students' critical reflection on mandatory team service-learning fosters development of their cognitive empathy and reflective capacity. We present a model program to incorporate critical reflection on service to the community throughout the curricula of all healthcare professions trainees.

EQUIP emergency: can interventions to reduce racism, discrimination and stigma in EDs improve outcomes?

Background

Despite a publicly funded system, health care in Canada has been shown to be deeply inequitable, particularly toward Indigenous people. Based on research identifying key dimensions of equity-oriented health care as being cultural safety, harm reduction and trauma- and violence-informed care, an intervention to promote equity at the organizational level was tested in primary health care, refined and adapted, and tested in Emergency Departments (EDs).

Methods

In partnership with clinical, community and Indigenous leaders in three diverse EDs in one Canadian province, we supported direct care staff to tailor and implement the intervention. Intervention activities varied in type and intensity at each site. Survey data were collected pre- and post-intervention from every consecutive patient over age 18 presenting to the EDs (n = 4771) with 3315 completing post-visit questions in 4 waves at two sites and 3 waves (due to pandemic constraints) at the third. Administrative data were collected for 12 months pre- and 12 months post-intervention.

Results

Throughout the study period, the participating EDs were dealing with a worsening epidemic of overdoses and deaths related to a toxic drug supply, and the COVID 19 pandemic curtailed both intervention activities and data collection. Despite these constraints, staff at two of the EDs mounted equity-oriented intervention strategies; the other site was experiencing continued, significant staff shortages and leadership changeover. Longitudinal analysis using multiple regression showed non-significant but encouraging trends in patient perceptions of quality of care and patient experiences of discrimination in the ED. Subgroup analysis showed that specific groups of patients experienced care in significantly different ways at each site. An interrupted time series of administrative data showed no significant change in staff sick time, but showed a significant decrease in the percentage of patients who left without care being completed at the site with the most robust intervention activities.

Conclusions

The trends in patient perceptions and the significant decrease in the percentage of patients who left without care being completed suggest potential for impact. Realization of this potential will depend on readiness, commitment and resources at the organizational and systems levels.

Trial registration

Clinical Trials.gov #NCT03369678 (registration date November 18, 2017).

Bias and discrimination in surgery: Where are we and what can we do about it?

Bias is an inclination or preconceived outlook that favors toward or against an idea, person, or group. It manifests in implicit and explicit ways throughout all aspects and institutions of society. These cognitive shortcuts are often based on stereotypes and can lead to prejudice and discrimination in medicine as they mediate interactions with patients, between providers, and at the institutional level. It is important to understand the drivers and consequences of bias in order to overcome barriers to representation, equity, and inclusion. This paper provides definitions of bias; discusses its manifestations across academic medicine at the institutional and individual levels; and concludes by examining techniques to reduce bias and measure progress. Equity for patients, families, and members of the broader surgical community cannot be achieved without reducing bias and discrimination. We call for action to increase intentional efforts that reduce the influences of bias in healthcare, research, and education, particularly in the field of pediatric surgery.

Battling Bias in Primary Care Encounters: Informatics Designs to Support Clinicians

Although clinical training in implicit bias is essential for healthcare equity, major gaps remain both for effective educational strategies and for tools to help identify implicit bias. To understand the perspectives of clinicians on the design of these needed strategies and tools, we conducted 21 semi-structured interviews with primary care clinicians about their perspectives and design recommendations for tools to improve patient-centered communication and to help mitigate implicit bias. Participants generated three types of solutions to improve communication and raise awareness of implicit bias: digital nudges, guided reflection, and data-driven feedback. Given the nuance of implicit bias communication feedback, these findings illustrate innovative design directions for communication training strategies that clinicians may find acceptable. Improving communication skills through individual feedback designed by clinicians for clinicians has the potential to improve healthcare equity.

Leveraging Machine Learning to Understand How Emotions Influence Equity Related Education: Quasi-Experimental Study

BACKGROUND

Teaching and learning about topics such as bias are challenging due to the emotional nature of bias-related discourse. However, emotions can be challenging to study in health professions education for numerous reasons. With the emergence of machine learning and natural language processing, sentiment analysis (SA) has the potential to bridge the gap.

OBJECTIVE

To improve our understanding of the role of emotions in bias-related discourse, we developed and conducted a SA of bias-related discourse among health professionals.

METHODS

We conducted a 2-stage quasi-experimental study. First, we developed a SA (algorithm) within an existing archive of interviews with health professionals about bias. SA refers to a mechanism of analysis that evaluates the sentiment of textual data by assigning scores to textual components and calculating and assigning a sentiment value to the text. Next, we applied our SA algorithm to an archive of social media discourse on Twitter that contained equity-related hashtags to compare sentiment among health professionals and the general population.

RESULTS

When tested on the initial archive, our SA algorithm was highly accurate compared to human scoring of sentiment. An analysis of bias-related social media discourse demonstrated that health professional tweets (n=555) were less neutral than the general population (n=6680) when discussing social issues on professionally associated accounts (χ² [2, n=555)]=35.455; P<.001), suggesting that health professionals attach more sentiment to their posts on Twitter than seen in the general population.

CONCLUSIONS

The finding that health professionals are more likely to show and convey emotions regarding equity-related issues on social media has implications for teaching and learning about sensitive topics related to health professions education. Such emotions must therefore be considered in the design, delivery, and evaluation of equity and bias-related education.

Dismantling Structural Stigma Related to Mental Health and Substance Use: An Educational Framework

Stigma related to mental health and substance use (MHSU) is a well-established construct that describes how inequitable health outcomes can result from prejudice, discrimination, and marginalization. Although there is a body of literature on educational approaches to reduce stigma, antistigma education for MHSU has primarily focused on stigma at the social, interpersonal/public, and personal (self-stigma) levels, with little attention to the problem of structural stigma. Structural stigma refers to how inequity is manifested through rules, policies, and procedures embedded within organizations and society at large. Structural stigma is also prominent within clinical learning environments and can be transmitted through role modeling, resulting in inequitable treatment of vulnerable patient populations. Addressing structural stigma through education, therefore, has the potential to improve equity and enhance care. A promising educational approach for addressing structural stigma is structural competency, which aims to enhance health professionals' ability to recognize and respond to social and structural determinants that produce or maintain health disparities. In this article, the authors propose a framework for addressing structural MHSU stigma in health professions education that has 4 key components and is rooted in structural humility: recognizing structural forms of stigma; reflecting critically on one's own assumptions, values, and biases; reframing language away from stereotyping toward empathic terms; and responding with actions that actively dismantle structural MHSU stigma. The authors propose evidence-informed and practical suggestions on how structural competency may be applied within clinical learning environments to dismantle structural MHSU stigma in organizations and society at large.

Walking the walk: Advice for anti-racist academic leaders

The importance of advancing anti-racism within research has gained recent attention. Academic medical organizations have attempted to increase diversity while seeking structural reforms to advance equity. However, efforts remain constrained while persons from racialized groups continue to experience discrimination. Mental health research is not immune to the experience of inequity. There is ample evidence that mental health research is underfunded compared to other types of health research. In addition, many racialized researchers and research staff have experienced different forms of implicit, explicit, and structural racism and are finding the courage to share their stories. Such experiences of racial trauma have a disastrous impact on the well-being of mental health researchers and adversely influence our overall mission. In this commentary, we also provide tangible and practical suggestions for academic leaders in the field. First, leaders must name racism and resist fragility and defensive reactions when the topic of racism in research is broached. Second, leaders should seek to foster a culture of belonging on teams where feedback from all is welcomed and encouraged. Third, leaders should seek structural change to ensure that teams are diverse and the adverse influence of systemic forms of racial discrimination on research our mitigated. Fourth, leaders must center the voices and perspective of those impacted by racial discrimination when developing, implementing, and evaluating their anti-racism work.

Eliminating Explicit and Implicit Biases in Health Care: Evidence and Research Needs

Health care providers hold negative explicit and implicit biases against marginalized groups of people such as racial and ethnic minoritized populations. These biases permeate the health care system and affect patients via patient–clinician communication, clinical decision making, and institutionalized practices. Addressing bias remains a fundamental professional responsibility of those accountable for the health and wellness of our populations. Current interventions include instruction on the existence and harmful role of bias in perpetuating health disparities, as well as skills training for the management of bias. These interventions can raise awareness of provider bias and engage health care providers in establishing egalitarian goals for care delivery, but these changes are not sustained, and the interventions have not demonstrated change in behavior in the clinical or learning environment. Unfortunately, the efficacy of these interventions may be hampered by health care providers’ work and learning environments, which are rife with discriminatory practices that sustain the very biases US health care professions are seeking to diminish. We offer a conceptual model demonstrating that provider-level implicit bias interventions should be accompanied by interventions that systemically change structures inside and outside the health care system if the country is to succeed in influencing biases and reducing health inequities.

Designing the careful and kind clinic: an evidence-based approach

Background

There is evidence that creating a ‘healthy workplace’ can be of profound importance for clinicians, team members and patients. Yet there have been few papers that have proposed mechanisms to take decades of research and translate this into a practical list of options for leaders and managers to take into account when structuring a clinic based on care and kindness to achieve optimal health.

Evidence

We bring together 20 years of scholarship linking care of the caregivers with outcomes for caregivers and patients. The data are used to support both structures and cultures that will result in satisfied and thriving healthcare team members, as well as satisfied and healthy patients.

Results

The clinic based on care of the caregivers will be structured to address key aspects of worklife that are known to cause either satisfaction or burnout. Aspects of care, such as time pressure, chaotic environments and worker control of their workplace, will be taken into account in clinical design; organisational culture will be supportive and cohesive, emphasising quality, values and communication. Experiences based on gender and race will be measured and continuously improved; and performance will be evaluated in a new, human-centred manner.

Outcomes

The careful and kind clinic will be a remarkable place to work; in contrast to industrialised healthcare, this will be an environment where health can indeed be optimised, for both workers and patients.

Leading through the first wave of COVID: a Canadian action research study

PURPOSE

This first phase of a three-phase action research project aims to define leadership practices that should be used during and after the pandemic to re-imagine and rebuild the health and social care system. Specifically, the objectives were to determine what effective leadership practices Canadian health leaders have used through the first wave of the COVID-19 pandemic, to explore how these differ from pre-crisis practices; and to identify what leadership practices might be leveraged to create the desired health and care systems of the future.

DESIGN/METHODOLOGY/APPROACH

The authors used an action research methodology. In the first phase, reported here, the authors conducted one-on-one, virtual interviews with 18 health leaders from across Canada and across leadership roles. Data were analyzed using grounded theory methodology.

FINDINGS

Five key practices emerged from the data, within the core dimension of disrupting entrenched structures and leadership practices. These were, namely, responding to more complex emotions in self and others. Future practice identified to create more psychologically supportive workplaces. Agile and adaptive leadership. Future practice should allow leaders to move systemic change forward more quickly. Integrating diverse perspectives, within and across organizations, leveling hierarchies through bringing together a variety of perspectives in the decision-making process and engaging people more broadly in the co-creation of strategies. Applying existing leadership capabilities and experience. Future practice should develop and expand mentorship to support early career leadership. Communication was increased to build credibility and trust in response to changing and often contradictory emerging evidence and messaging. Future practice should increase communication.

RESEARCH LIMITATIONS/IMPLICATIONS

The project was limited to health leaders in Canada and did not represent all provinces/territories. Participants were recruited through the leadership networks, while diverse, were not demographically representative. All interviews were conducted in English; in the second phase of the study, the authors will recruit a larger and more diverse sample and conduct interviews in both English and French. As the interviews took place during the early stages of the pandemic, it may be that health leaders' views of what may be required to re-define future health systems may change as the crisis shifts over time.

PRACTICAL IMPLICATIONS

The sponsoring organization of this research - the Canadian Health Leadership Network and each of its individual member partners - will mobilize knowledge from this research, and subsequent phases, to inform processes for leadership development and, succession planning across, the Canadian health system, particularly those attributes unique to a context of crisis management but also necessary in post-crisis recovery.

SOCIAL IMPLICATIONS

This research has shown that there is an immediate need to develop innovative and influential leadership action - commensurate with its findings - to supporting the evolution of the Canadian health system, the emotional well-being of the health-care workforce, the mental health of the population and challenges inherent in structural inequities across health and health care that discriminate against certain populations.

ORIGINALITY/VALUE

An interdisciplinary group of health researchers and decision-makers from across Canada who came together rapidly to examine leadership practices during COVID-19's first wave using action research study design.

Strategies to Reduce Bias and Racism in Nursing Precepted Clinical Experiences

BACKGROUND

Nursing programs are tasked with ensuring diverse, equitable, and inclusive (DEI) learning environments for all student learners. With calls to diversify the nursing workforce, engaging nursing preceptors in program-wide DEI initiatives are crucial. Preceptors lacking commitment to DEI could result in poor patient-preceptor communication, tense learning environments, or biased evaluations of students.

METHOD

Suggestions for successful strategies to include the preceptor in nursing program's antiracism initiatives are based on the current literature.

RESULTS

Best practices include providing antiracism training for preceptors, decreasing potential for bias in student evaluations, inquiring about observed racism in clinical sites, and equipping students to be upstanders for antiracism and DEI interventions.

CONCLUSION

Dismantling racism and bias in nursing education requires a multilevel strategy. Nursing programs and nurse educators have a responsibility for ensuring a bias-free learning environment and should include the preceptor in antiracism strategic planning. [J Nurs Educ. 2021;60(12):697-702.].

Understanding Healthcare Students' Experiences of Racial Bias: A Narrative Review of the Role of Implicit Bias and Potential Interventions in Educational Settings

Implicit racial bias is a persistent and pervasive challenge within healthcare education and training settings. A recent systematic review reported that 84% of included studies (31 out of 37) showed evidence of slight to strong pro-white or light skin tone bias amongst healthcare students and professionals. However, there remains a need to improve understanding about its impact on healthcare students and how they can be better supported. This narrative review provides an overview of current evidence regarding the role of implicit racial bias within healthcare education, considering trends, factors that contribute to bias, and possible interventions. Current evidence suggests that biases held by students remain consistent and may increase during healthcare education. Sources that contribute to the formation and maintenance of implicit racial bias include peers, educators, the curriculum, and placements within healthcare settings. Experiences of implicit racial bias can lead to psychosomatic symptoms, high attrition rates, and reduced diversity within the healthcare workforce. Interventions to address implicit racial bias include an organizational commitment to reducing bias in hiring, retention, and promotion processes, and by addressing misrepresentation of race in the curriculum. We conclude that future research should identify, discuss, and critically reflect on how implicit racial biases are enacted and sustained through the hidden curriculum and can have detrimental consequences for racial and ethnic minority healthcare students.

Twelve tips for teaching implicit bias recognition and management

Implicit biases describe mental associations that affect our actions in an unconscious manner. We can hold certain implicit biases regarding members of certain social groups. Such biases can perpetuate health disparities by widening inequity and decreasing trust in both healthcare and medical education. Despite the widespread discourse about bias in medical education, teaching and learning about the topic should be informed by empirical research and best practice. In this paper, the authors provide a series of twelve tips for teaching implicit bias recognition and management in medical education. Each tip provides a specific and practical strategy that is theoretically and empirically developed through research and evaluation. Ultimately, these twelve tips can assist educators to incorporate implicit bias instruction across the continuum of medical education to improve inequity and advance justice.

Navigating Ethical Challenges for Pediatric Sickle Cell Pain Management in the Context of the Opioid Epidemic

OBJECTIVES

The aim was to describe the impact of the opioid epidemic on pain management practices in pediatric sickle cell disease (SCD) and propose a conceptual framework for navigating ethical decision-making in pediatric sickle cell pain management.

METHODS

A review of the literature on ethical challenges in the management of sickle cell pain was conducted and considered in the context of the opioid epidemic and psychosocial factors affecting youth with SCD. The Integrated Ethical Framework for Pain Management (IEFPM) was applied to pediatric sickle cell pain management using a clinical case example.

RESULTS

Implicit bias, health-related stigma, and potential neurocognitive impairment all present unique challenges in ethical decision-making for youth with SCD. National guidelines for prescribing opioid medication may complicate providers' clinical decision-making and affect their sickle cell pain management practices. The IEFPM was found to be applicable to ethical decision-making for pediatric sickle cell pain and captures both patient-related and provider-related aspects of clinical pain management.

DISCUSSION

The opioid epidemic has exacerbated existing ethical challenges for pain management among youth with SCD. The IEFPM provides a conceptual model that can be integrated into health care settings to facilitate ethical decision-making and promote greater health equity in the clinical management of pediatric sickle cell pain.

The reduction of race and gender bias in clinical treatment recommendations using clinician peer networks in an experimental setting

Bias in clinical practice, in particular in relation to race and gender, is a persistent cause of healthcare disparities. We investigated the potential of a peer-network approach to reduce bias in medical treatment decisions within an experimental setting. We created "egalitarian" information exchange networks among practicing clinicians who provided recommendations for the clinical management of patient scenarios, presented via standardized patient videos of actors portraying patients with cardiac chest pain. The videos, which were standardized for relevant clinical factors, presented either a white male actor or Black female actor of similar age, wearing the same attire and in the same clinical setting, portraying a patient with clinically significant chest pain symptoms. We found significant disparities in the treatment recommendations given to the white male patient-actor and Black female patient-actor, which when translated into real clinical scenarios would result in the Black female patient being significantly more likely to receive unsafe undertreatment, rather than the guideline-recommended treatment. In the experimental control group, clinicians who were asked to independently reflect on the standardized patient videos did not show any significant reduction in bias. However, clinicians who exchanged real-time information in structured peer networks significantly improved their clinical accuracy and showed no bias in their final recommendations. The findings indicate that clinician network interventions might be used in healthcare settings to reduce significant disparities in patient treatment.

Patient and provider perspectives on preterm birth risk assessment and communication

OBJECTIVE

To describe and compare how obstetric patients and care providers view preterm birth risk assessment and communication.

METHODS

We conducted eight focus groups with obstetric patients (n = 35) and 16 qualitative interviews with obstetric providers. Grounded theory was used to identify and analyze themes.

RESULTS

Patients' knowledge about preterm birth varied greatly. Similar benefits and risks of preterm birth risk counseling were discussed by patients and providers with notable exceptions: patients cited preparedness as a benefit and providers cited maternal blame, patient alienation, and estimate uncertainty as potential risks. Most patients expressed a desire to know their personalized preterm birth risk during pregnancy. Providers differed in whether they offer universal versus selective, and quantitative versus qualitative, preterm birth risk counseling. Many providers expressed concern about discussing social and structural risk factors for preterm birth.

CONCLUSION

While many patients desired knowing their personalized preterm birth risk, prenatal care providers' disclosure practices vary because of uncertainty of estimates, concerns about negative consequences and challenges of addressing systemic inequities and social determinants of health.

PRACTICE IMPLICATIONS

Given the existing asymmetry of information about preterm birth risk, providers should consider patient preferences regarding and potential benefits and risks of such disclosure in their practice.

Implementation and Evaluation of a 10-Week Health Equity Curriculum for Pharmacy Students

Objective To describe a health equity curriculum created for pharmacy students and evaluate students' perceptions and structural competency after completion of the curriculum.Methods A health equity curriculum based on transformative learning and structural competency frameworks was implemented as a 10-week mandatory component of the pass-no pass neuropsychiatric theme for second year pharmacy students. Each week, students reviewed materials around a neuropsychiatric-related health equity topic and responded to discussion prompts through asynchronous forums or synchronous online video discussions. The effectiveness of the health equity curriculum was evaluated through assessment of structural competency through a validated instrument, an objective structured clinical examination (OSCE), and a questionnaire.Results All enrolled second year pharmacy students (n=124) participated in the health equity curriculum. Of the 75 students who completed the structural competency instrument, 46 (61%) were able to identify structural determinants of health, explain how structures contribute to health disparities, or design structural interventions. Ninety-six of the 124 students (77%) were able to address their OSCE standardized patient's mistrust in the health care system. Thematic analysis of student comments elucidated three themes: allyship, peer connection, and self-awareness. Students rated asynchronous discussion forums as significantly less effective than online video discussions and patient cases for achieving curricular objectives.Conclusion A mandatory curriculum delivered remotely throughout the didactic pharmacy curriculum using a blended learning approach was an effective way to incorporate health equity content and conversations into existing courses. Implementation of this or similar curriculums could be an important step in training pharmacy students to be advocates for social justice.

Coping, Anxiety, and Health Care Transition Readiness in Youth with Chronic Conditions

PURPOSE

To explore the relationship between coping and health care transition readiness, and to examine whether anxiety is a mediator between coping and health care transition readiness.

DESIGN AND METHODS

A sample of 174 youths with various chronic conditions (age 13.03 ± 2.02 years, 48.3% male) attending the 2018 Victory Junction Camp and their parents participated. Youths and parents completed measures to assess coping (Kidcope Checklist), anxiety symptoms (PROMIS Anxiety scale), and transition readiness (STARx Questionnaire) through Qualtrics online surveys.

RESULTS

Positive coping was positively related to transition readiness in both youth and parent-proxy reports, while negative coping was negatively related to transition readiness in youth reports. Anxiety mediated the relationship of positive coping and transition readiness in parent-proxy reports, and the relationship of negative coping and transition readiness in both youth self-reports and parent-reports.

CONCLUSIONS

Coping is an important factor in transition readiness. Furthermore, anxiety is an important mediator, and may be more influential in the relationship of negative coping and transition readiness.

PRACTICE IMPLICATIONS

Practitioners and health care providers can use these findings to promote the use of positive coping and reduce the use of negative coping, which in turn may improve outcomes for youth with chronic health conditions who are transitioning to adult health care services.

Gender imbalance amongst promotion and leadership in academic surgical programs in Canada: A cross-sectional Investigation

BACKGROUND

Women are underrepresented at higher levels of promotion or leadership despite the increasing number of women physicians. In surgery, this has been compounded by historical underrepresentation. With a nation-wide focus on the importance of diversity, our aim was to provide a current snapshot of gender representation in Canadian universities.

METHODS

This cross-sectional online website review assessed the current faculty listings for 17 university-affiliated academic surgical training departments across Canada in the 2019/2020 academic year. Gender diversity of academic surgical faculty was assessed across surgical disciplines. Additionally, gender diversity in career advancement, as described by published leadership roles, promotion and faculty appointment, was analyzed.

RESULTS

Women surgeons are underrepresented across Canadian surgical specialties (totals: 2,689 men versus 531 women). There are significant differences in the gender representation of surgeons between specialties and between universities, regardless of specialty. Women surgeons had a much lower likelihood of being at the highest levels of promotion (OR: 0.269, 95% CI: 0.179-0.405). Men surgeons were statistically more likely to hold academic leadership positions than women (p = 0.0002). Women surgeons had a much lower likelihood of being at the highest levels of leadership (OR: 0.372, 95% CI: 0.216-0.641).

DISCUSSION

This study demonstrates that women surgeons are significantly underrepresented at the highest levels of academic promotion and leadership in Canada. Our findings allow for a direct comparison between Canadian surgical subspecialties and universities. Individual institutions can use these data to critically appraise diversity policies already in place, assess their workforce and apply a metric from which change can be measured.

Project Inclusive Genetics: Exploring the impact of patient-centered counseling training on physical disability bias in the prenatal setting

PURPOSE

There is robust research examining the negative impact of racial and socioeconomic implicit bias on healthcare provider clinical decision-making. However, other under-studied important biases are likely to impact clinical care as well. The goal of this study was to explore the presence of bias against people with physical disability among a heterogeneous group of healthcare workers and trainees and to evaluate the effect of implicit association testing and an educational module on this bias.

METHOD

The study was composed of a one-hour web-based survey and educational module. The survey included an explicit disability bias assessment, disability Implicit Association Tests (IATs), demographic collection, and pre- and post- module clinical vignettes of prenatal patient scenarios. In addition to providing counseling to hypothetical patients, participants also indicated their personal preferences on genetic testing and termination. The educational module focused on the principles of patient-centered counseling.

RESULTS

The collected data reflects responses from 335 participants. Within this sample, there were both explicit and implicit biases towards individuals with physical disabilities. Prior to the IAT and educational module, when respondents were tasked with providing genetic testing recommendations, implicit biases and personal preferences for genetic testing and termination influenced respondents' clinical recommendations. Importantly, having previous professional experience with individuals with disabilities diminished biased clinical recommendations prior to the intervention. In response to the IAT and educational intervention, the effect of implicit bias and personal preferences on clinical recommendations decreased.

CONCLUSIONS

This study demonstrates how bias against a marginalized group exists within the medical community and that personal opinions can impact clinical counseling. Importantly, our findings suggest that there are strategies that can be easily implemented into curricula to address disability bias, including formal educational interventions and the addition of professional experiences into healthcare professional training programs.

Recommendations and Guidelines for the Use of Simulation to Address Structural Racism and Implicit Bias

SUMMARY STATEMENT

Simulation-based education is a particularly germane strategy for addressing the difficult topic of racism and implicit bias due to its immersive nature and the paradigm of structured debriefing. Researchers have proposed actionable frameworks for implicit bias education, particularly outlining the need to shift from recognition to transformation, with the goal of changing discriminatory behaviors and policies. As simulation educators tasked with training health care professionals, we have an opportunity to meet this need for transformation. Simulation can shift behaviors, but missteps in design and implementation when used to address implicit bias can also lead to negative outcomes. The focus of this article is to provide recommendations to consider when designing simulation-based education to specifically address racism and implicit bias.

Moving Towards Racial Equity in the Child and Youth Mental Health Sector in Ontario, Canada

In the aftermath of high-profile incidents involving Black, Indigenous and People of Color (BIPOC) in North America, there is a growing awareness of the pervasiveness of systemic racism and the role that agencies play in perpetuating racism and racial inequities. In the child and youth mental health sector, the journey to improving racial equity is impeded by a lack of consistent frameworks or guidelines. In this commentary, we explore five domains of organizational practices that are prominent in the literature and support diverse clients, communities and staff, including: (1) organizational leadership and commitment, (2) inter-organizational and multisectoral partnerships, (3) workforce diversity and development, (4) client and community needs and engagement, and (5) continuous improvement. As we highlight these domains, we urge researchers, policy makers, and child and youth mental health service providers to work together to advance racial equity in meaningful ways.

Implicit Bias Recognition and Management in Interpersonal Encounters and the Learning Environment: A Skills-Based Curriculum for Medical Students

Introduction

Students desire instruction in skill development to address both their own implicit biases and bias perceived in the learning environment. Curricula to date achieve strategy identification through reflection and discussion but do not provide opportunity for personally relevant skill development and practice in implicit bias recognition and management. To address this gap, we developed and evaluated a skills-based elective in implicit bias recognition and management focused on learners' own interpersonal interactions, including patient encounters, and perceived bias in the learning environment.

Method

Fifteen first-year medical students completed the nine-session elective over three annual offerings. Each session lasted 1.5 hours. Curriculum development was informed by published frameworks and transformative learning theory. Direct observation of student performances in role-plays and other active learning exercises constituted the formative assessment. Program evaluation focused on the impact of instruction through pre- and posttests, along with analysis of notes taken by the investigative team, including notes on formative assessments.

Results

Students engaged with all aspects of instruction, including role-plays. Pretest/posttest results demonstrated increased self-reported knowledge and comfort in addressing perceived bias. Formative assessment demonstrated students' skill development in safely and respectfully addressing perceived bias in the learning environment without endangering their relationships with supervisors.

Discussion

Skills developed-addressing bias in interpersonal encounters and perceived bias in clinical and teaching encounters-are relevant to learners throughout their careers. This course is relevant to medical students and trainees at various experience levels and could serve as a template for novel, skills-based curricula across health professions.

Qualitative analysis of medical student reflections on the implicit association test

INTRODUCTION

Health professions educators use the Implicit Association Test (IAT) to raise awareness of implicit bias in learners, often engendering strong emotional reactions. Once an emotional reaction ensues, the gap between learner reaction and strategy identification remains relatively underexplored. To better understand how learners may identify bias mitigation strategies, the authors explored perspectives of medical students during the clinical portion of their training to the experience of taking the IAT, and the resulting feedback.

METHODS

Medical students in Bronx, NY, USA, participated in one 90-minute session on implicit bias. The focus of analysis for this study is the post-session narrative assignment inviting them to take the race-based IAT and describe both their reaction to and the implications of their IAT results on their future work as physicians. The authors analysed 180 randomly selected de-identified essays completed from 2013 to 2019 using an approach informed by constructivist grounded theory methodology.

RESULTS

Medical students with clinical experience respond to the IAT through a continuum that includes their reactions to the IAT, acceptance of bias along with a struggle for strategy identification, and identification of a range of strategies to mitigate the impact of bias on clinical care. Results from the IAT invoked deep emotional reactions in students, and facilitated a questioning of previous assumptions, leading to paradigm shifts. An unexpected contrast to these deep and meaningful reflections was that students rarely chose to identify a strategy, and those that did provided strategies that were less nuanced.

CONCLUSION

Despite accepting implicit bias in themselves and desiring to provide unbiased care, students struggled to identify bias mitigation strategies, a crucial prerequisite to skill development. Educators should endeavour to expand instruction to bridge the chasm between students' acceptance of bias and skill development in management of bias to improve the outcomes of their clinical encounters.

Impact of a Pandemic and Remote Learning on Team Development and Elements of Compassion in Prospective Medical Students Taking a Medical Humanities Course

INTRODUCTION

We reported previously that when teams of students reflect on readings about communication, unconscious bias, and service-learning, their critical reflection, implicit bias mitigation, empathy, and compassionate behavior all increase. However, would these gains occur when intimate classroom settings, in-person team meetings, and direct interactions with people served were lost owing to the COVID-19 pandemic and remote learning?

METHODS

Before an online Medical Humanities course began in August 2020 and following the course in December 2020, 61 prospective medical students (54.1% female) completed reliable surveys of their reflective capacity (RC) and cognitive empathy (compassion). Students also completed surveys about their implicit biases and team community service in December 2020.

RESULTS

Both RC and empathy scores increased in students after they reflected on difficulties in communication, unconscious biases, and team service-learning experiences in the course. In written reflections, they reported how their compassionate behavior also grew owing to bias mitigation. Most students concurred that "unconscious bias might affect some of (their) clinical decisions or behaviors as a healthcare professional" and vowed to remain aware of these biases in clinical settings.

CONCLUSIONS

Compared to previous years, the pandemic and remote learning had minimal effects on the benefits of our Medical Humanities course.

Validity evidence for a novel instrument assessing medical student attitudes toward instruction in implicit bias recognition and management

BACKGROUND

Implicit bias instruction is becoming more prevalent in health professions education, with calls for skills-based curricula moving from awareness and recognition to management of implicit bias. Evidence suggests that health professionals and students learning about implicit bias ("learners") have varying attitudes about instruction in implicit bias, including the concept of implicit bias itself. Assessing learner attitudes could inform curriculum development and enable instructional designs that optimize learner engagement. To date, there are no instruments with evidence for construct validity that assess learner attitudes about implicit bias instruction and its relevance to clinical care.

METHODS

The authors developed a novel instrument, the Attitude Towards Implicit Bias Instrument (ATIBI) and gathered evidence for three types of construct validity- content, internal consistency, and relationship to other variables.

RESULTS

Authors utilized a modified Delphi technique with an interprofessional team of experts, as well as cognitive interviews with medical students leading to item refinement to improve content validity. Seven cohorts of medical students, N = 1072 completed the ATIBI. Psychometric analysis demonstrated high internal consistency (α = 0.90). Exploratory factor analysis resulted in five factors. Analysis of a subset of 100 medical students demonstrated a moderate correlation with similar instruments, the Integrative Medicine Attitude Questionnaire (r = 0.63, 95% CI: [0.59, 0.66]) and the Internal Motivation to Respond Without Prejudice Scale (r = 0.36, 95% CI: [0.32, 0.40]), providing evidence for convergent validity. Scores on our instrument had low correlation to the External Motivation to Respond Without Prejudice Scale (r = 0.15, 95% CI: [0.09, 0.19]) and the Groningen Reflection Ability Scale (r = 0.12, 95% CI: [0.06, 0.17]) providing evidence for discriminant validity. Analysis resulted in eighteen items in the final instrument; it is easy to administer, both on paper form and online.

CONCLUSION

The Attitudes Toward Implicit Bias Instrument is a novel instrument that produces reliable and valid scores and may be used to measure medical student attitudes related to implicit bias recognition and management, including attitudes toward acceptance of bias in oneself, implicit bias instruction, and its relevance to clinical care.

Implicit bias in healthcare: clinical practice, research and decision making

Bias is the evaluation of something or someone that can be positive or negative, and implicit or unconscious bias is when the person is unaware of their evaluation. This is particularly relevant to policymaking during the coronavirus pandemic and racial inequality highlighted during the support for the Black Lives Matter movement. A literature review was performed to define bias, identify the impact of bias on clinical practice and research as well as clinical decision making (cognitive bias). Bias training could bridge the gap from the lack of awareness of bias to the ability to recognise bias in others and within ourselves. However, there are no effective debiasing strategies. Awareness of implicit bias must not deflect from wider socio-economic, political and structural barriers as well ignore explicit bias such as prejudice.

Equal means equal: Cardiothoracic surgery in its second century

OBJECTIVE

As the specialty of cardiothoracic surgery turns the corner into its second century of existence, there has been an uptick in the number of women and underrepresented minorities entering the field, but we have a long way to go before race and gender equity prevails.

METHODS

In this report, specific barriers to diversity without exclusion and mechanisms to breakdown these barriers will be explored.

RESULTS

Barriers to inclusion include a long-standing deficiency in exposure, encouragement, mentorship, and sponsorship to actively attract underrepresented groups to the specialty. Diversity will not occur passively. It will take a concerted effort best employed through a top-down approach at the local and national level, and it has to seem normal.

CONCLUSIONS

Cardiothoracic surgery is an outstanding field for anyone and everyone who seeks a challenging, rewarding career, regardless of their gender, race, or ethnic background. It is the responsibility of leadership to dispel the tradition that certain individuals are not welcome.

It Can Be Done! A Skills-Based Elective in Implicit Bias Recognition and Management for Preclinical Medical Students

PURPOSE

Students perceive bias in learning environments. Curricula targeting implicit bias recognition and management increase student awareness and achieve strategy identification, but fall short of actual skill development to address bias. In light of this gap, the authors developed and evaluated a skills-based elective to recognize and manage implicit bias in the learning environment.

METHOD

Nine 1.5-hour sessions were delivered to 15 first-year medical students from 2017 to 2019. An evidence-based conceptual framework and transformative learning theory informed the instructional design; it incorporated active learning exercises. Skills assessment occurred through direct observation of student performances in role-play exercises. Using thematic analysis, the authors conducted a program evaluation based on focus groups with students and data from notes taken by the investigative team.

RESULTS

Students engaged with all aspects of instruction, including role-plays. Authors identified 3 themes from the program evaluation: (1) Student engagement can be enhanced, (2) Instruction is empowering, and (3) It (addressing bias in one's own and witnessed encounters) can be done! Analysis additionally highlighted opportunities for improvement and lessons learned.

CONCLUSIONS

This innovative course achieved skill development and practice for medical students in implicit bias recognition and management as it pertains to 3 facets of clinical care present at every stage of a health professional's career. These include interpersonal encounters, advocating for patients when bias is perceived in witnessed encounters with peers and supervisors, and addressing comments made by others within the learning environment. Outcomes could inform novel, skills-based curricula across the spectrum of health professions training and practice.

A Narrative Study of Equity in Clinical Assessment Through the Antideficit Lens

PURPOSE

Efforts to address inequities in medical education are centered on a dialogue of deficits that highlight negative underrepresented in medicine (UIM) learner experiences and lower performance outcomes. An alternative narrative explores perspectives on achievement and equity in assessment. This study sought to understand UIM learner perceptions of successes and equitable assessment practices.

METHOD

Using narrative research, investigators selected a purposeful sample of self-identified UIM fourth-year medical students and senior-level residents and conducted semistructured interviews. Questions elicited personal stories of achievement during clinical training, clinical assessment practices that captured achievement, and equity in clinical assessment. Using re-storying and thematic analysis, investigators coded transcripts and synthesized data into themes and representative stories.

RESULTS

Twenty UIM learners (6 medical students and 14 residents) were interviewed. Learners often thought about equity during clinical training and provided personal definitions of equity in assessment. Learners shared stories that reflected their achievements in patient care, favorable assessment outcomes, and growth throughout clinical training. Sound assessments that captured achievements included frequent observations with real-time feedback on predefined expectations by supportive, longitudinal clinical supervisors. Finally, equitable assessment systems were characterized as sound assessment systems that also avoided comparison to peers, used narrative assessment, assessed patient care and growth, trained supervisors to avoid bias, and acknowledged learner identity.

CONCLUSIONS

UIM learners characterized equitable and sound assessment systems that captured achievements during clinical training. These findings guide future efforts to create an inclusive, fair, and equitable clinical assessment experience.

Making the implicit explicit: A visual model for lowering the risk of implicit bias of mental/behavioural disorders on safety and quality of care

Persons with mental illness and/or addictions have poorer health outcomes than the general population. Lower quality of healthcare has been identified as an important factor. A main contributor to lower quality of care for people with mental illnesses and/or addictions may be the cognitive implicit bias of mental versus physical care when assessing and categorizing a patient’s clinical presentation. The objective of this article is to highlight how this implicit cognitive bias of mental versus physical care can result in human factor risks to quality of care. We provide three specific case examples of where these quality concerns arise. We also propose the use of a new visual tool to help educate and create awareness of this implicit-bias-based risk and quality care problem.

'Too male, too pale, too stale': a qualitative exploration of student experiences of gender bias within medical education

OBJECTIVE

To explore medical student perceptions and experiences of gender bias within medical education.

SETTING

Gender bias-'prejudiced actions or thoughts based on the perception that women are not equal to men'-is a widespread issue. Within medicine, the pay gap, under-representation of women in senior roles and sexual harassment are among the most concerning issues demonstrating its presence and impact. While research investigating experiences of clinicians is gaining traction, investigation of medical students' experiences is lacking. This qualitative study analyses medical students' experiences of gender bias within their education to discern any patterns to this bias. Illuminating the current state of medical education gender bias will hopefully highlight areas in which student experience could be improved. Constructivist thematic analysis was used to analyse data, informed by William's patterns of gender bias, intersectional feminism and communities of practice theory.

PARTICIPANTS

Thirty-two medical students from multiple UK medical schools participated in individual interviews. Nine faculty members were also interviewed to triangulate data.

RESULTS

Gender bias has an overt presence during medical student education, manifesting in line with William's patterns of bias, impacting career aspirations. Physical environments serve to manifest organisational values, sending implicit messages regarding who is most welcome-currently, this imagery remains 'too male, too pale…too stale'. Existing gender initiatives require careful scrutiny, as this work identifies the superficial application of positive action, and a failure to affect meaningful change.

CONCLUSIONS

Despite progress having been made regarding overt gender discrimination, implicit bias persists, with existing positive action inadequate in promoting the advancement of women. Institutions should mandate participation in implicit bias education programmes for all staff and must strive to revise the imagery within physical environments to better represent society. Gender initiatives, like Athena Scientific Women's Academic Network, also require large-scale evaluation regarding their impact, which this work found to be lacking.

Fostering Empathy, Implicit Bias Mitigation, and Compassionate Behavior in a Medical Humanities Course

Increases in compassionate behavior improve patient outcomes and reduce burnout among healthcare professionals. We predicted that selecting and performing service-learning projects by teams of prospective medical students in a Medical Humanities course would foster students' compassion by raising their reflective capacity, empathy, and unconscious bias mitigation. In class, we discussed difficulties in communication and implicit bias. In this observational study, teams wrote individual and team critical reflections on these class discussions and their service-learning experiences, and we analyzed these reflections for dissonance, self-examination, bias mitigation, dissonance reconciliation, and compassionate behavior. Thirty-two students (53% female) completed the Reflective Practice Questionnaire and the Jefferson Scale of Empathy before the course in August 2019 and after it in December 2019. In December, students were surveyed concerning their attitudes toward team service-learning projects and unconscious bias. The students reported changes in their behavior to mitigate biases and become more compassionate, and their reflective capacity and empathy grew in association with discussions and team service-learning experiences in the course. Virtually all students agreed with the statement "Unconscious bias might affect some of my clinical decisions or behaviors as a healthcare professional," and they worked to control such biases in interactions with the people they were serving.

Visiting Jack: Mixed Methods Evaluation of a Virtual Home Visit Curriculum With a Child With Medical Complexity

BACKGROUND

There are limited training opportunities for pediatricians in caring for children with medical complexity (CMC) in the home and community. Prior studies have described a lack of comfort caring for CMC among pediatric residents.

OBJECTIVE

1) To evaluate the impact of participation in a virtual home visit curriculum on pediatric residents' confidence, knowledge, and application of knowledge in complex care; 2) to explore changes in perspectives relating to the care of CMC after participation in the curriculum.

METHODS

This was a prospective pre-post intervention study in 2019 with first-year pediatric residents, using quantitative and qualitative methods. The intervention, co-created with a family partner, was an online video-based curriculum followed by an in-person seminar. Pre- and postassessments were compared using paired t tests. Follow-up interviews and focus groups were performed 5 to 8 weeks after training. Transcripts were analyzed using inductive thematic analysis.

RESULTS

Twenty-four residents (100%) participated. Residents reported increased confidence in all aspects of complex care presented in the curriculum, with significant increase in knowledge and application of knowledge (all P < .001). Twelve residents (50%) participated in a follow-up interview or focus group. Four themes were identified: 1) recognizing prior attitudes toward complexity, 2) new mental framework for complex care at home, 3) drivers of behavior change, and 4) commitment to change practice.

CONCLUSIONS

Participation in this curriculum was associated with increased confidence, knowledge, and application of knowledge in complex care outside of the hospital. Qualitative findings align with transformative learning theory, lending insight into effective approaches to complex care training.