When best intentions aren't enough: helping medical students develop strategies for managing bias about patients

Anti-stigma advocacy for health professionals: a systematic review

BACKGROUND

Many anti-stigma programs for healthcare workers already exist however there is less research on the effectiveness of training in skills for health professionals to counter stigma and its impacts on patients.

AIMS

The objective of this study was to examine the theory base, content, delivery, and outcomes of interventions for healthcare professionals which aim to equip them with knowledge and skills to aid patients to mitigate stigma and discrimination and their health impacts.

METHODS

Five electronic databases and grey literature were searched. Data were screened by two independent reviewers, conflicts were discussed. Quality appraisal was realized using the ICROMS tool. A narrative synthesis was carried out.

RESULTS

The final number of studies was 41. In terms of theory base, there are three strands - responsibility as part of the professional role, correction of wrongful practices, and collaboration with local communities. Content focusses either on specific groups experiencing health-related stigma or health advocacy in general.

CONCLUSIONS

Findings suggest programs should link definitions of stigma to the role of the professional. They should be developed following a situational analysis and include people with lived experience. Training should use interactive delivery methods. Evaluation should include follow-up times that allow examination of behavioural change. PROSPERO, ID: CRD42020212527.

Smartphone-Based Virtual and Augmented Reality Implicit Association Training (VARIAT) for Reducing Implicit Biases Toward Patients Among Health Care Providers: App Development and Pilot Testing

Background

Implicit bias is as prevalent among health care professionals as among the wider population and is significantly associated with lower health care quality.

Objective

The study goal was to develop and evaluate the preliminary efficacy of an innovative mobile app, VARIAT (Virtual and Augmented Reality Implicit Association Training), to reduce implicit biases among Medicaid providers.

Methods

An interdisciplinary team developed 2 interactive case-based training modules for Medicaid providers focused on implicit bias related to race and socioeconomic status (SES) and sexual orientation and gender identity (SOGI), respectively. The simulations combine experiential learning, facilitated debriefing, and game-based educational strategies. Medicaid providers (n=18) participated in this pilot study. Outcomes were measured on 3 domains: training reactions, affective knowledge, and skill-based knowledge related to implicit biases in race/SES or SOGI.

Results

Participants reported high relevance of training to their job for both the race/SES module (mean score 4.75, SD 0.45) and SOGI module (mean score 4.67, SD 0.50). Significant improvement in skill-based knowledge for minimizing health disparities for lesbian, gay, bisexual, transgender, and queer patients was found after training (Cohen d=0.72; 95% CI -1.38 to -0.04).

Conclusions

This study developed an innovative smartphone-based implicit bias training program for Medicaid providers and conducted a pilot evaluation on the user experience and preliminary efficacy. Preliminary evidence showed positive satisfaction and preliminary efficacy of the intervention.

Racial Implicit Bias and Communication Among Physicians in a Simulated Environment

Importance

Racial implicit bias can contribute to health disparities through its negative influence on physician communication with Black patients. Interventions for physicians to address racial implicit bias in their clinical encounters are limited by a lack of high-fidelity (realistic) simulations to provide opportunities for skill development and practice.

Objective

To describe the development and initial evaluation of a high-fidelity simulation of conditions under which physicians might be influenced by implicit racial bias.

Design, Setting, and Participants

This cross-sectional study, performed on an online platform from March 1 to September 30, 2022, recruited a convenience sample of physician volunteers to pilot an educational simulation.

Exposures

In the simulation exercise, physicians saw a 52-year-old male standardized patient (SP) (presenting as Black or White) seeking urgent care for epigastric pain, nausea, and vomiting. The case included cognitive stressors common to clinical environments, including clinical ambiguity, stress, time constraints, and interruptions. Physicians explained their diagnosis and treatment plan to the SP, wrote an assessment and management plan, completed surveys, and took the Race Implicit Association Test (IAT) and Race Medical Cooperativeness IAT. The SPs, blinded to the purpose of the study, assessed each physician's communication using skills checklists and global rating scales.

Main Outcomes and Measures

Association between physicians' IAT scores and SP race with SP ratings of communication skills.

Results

In 60 physicians (23 [38.3%] Asian, 4 [6.7%] Black, 23 [38.3%] White, and 10 [16.7%] other, including Latina/o/x, Middle Eastern, and multiracial; 31 [51.7%] female, 27 [45.0%] male, and 2 [3.3%] other), the interaction of physicians' Race IAT score and SP race was significant for overall communication (mean [SD] β = -1.29 [0.41]), all subdomains of communication (mean [SD] β = -1.17 [0.52] to -1.43 [0.59]), and overall global ratings (mean [SD] β = -1.09 [0.39]). Black SPs rated physicians lower on communication skills for a given pro-White Race IAT score than White SPs; White SP ratings increased as physicians' pro-White bias increased.

Conclusions and Relevance

In this cross-sectional study, a high-fidelity simulation calibrated with cognitive stressors common to clinical environments elicited the expected influence of racial implicit bias on physicians' communication skills. The outlined process and preliminary results can inform the development and evaluation of interventions that seek to address racial implicit bias in clinical encounters and improve physician communication with Black patients.

A scoping review to identify and organize literature trends of bias research within medical student and resident education

BACKGROUND

Physician bias refers to the unconscious negative perceptions that physicians have of patients or their conditions. Medical schools and residency programs often incorporate training to reduce biases among their trainees. In order to assess trends and organize available literature, we conducted a scoping review with a goal to categorize different biases that are studied within medical student (MS), resident (Res) and mixed populations (MS and Res). We also characterized these studies based on their research goal as either documenting evidence of bias (EOB), bias intervention (BI) or both. These findings will provide data which can be used to identify gaps and inform future work across these criteria.

METHODS

Online databases (PubMed, PsycINFO, WebofScience) were searched for articles published between 1980 and 2021. All references were imported into Covidence for independent screening against inclusion criteria. Conflicts were resolved by deliberation. Studies were sorted by goal: 'evidence of bias' and/or 'bias intervention', and by population (MS or Res or mixed) andinto descriptive categories of bias.

RESULTS

Of the initial 806 unique papers identified, a total of 139 articles fit the inclusion criteria for data extraction. The included studies were sorted into 11 categories of bias and showed that bias against race/ethnicity, specific diseases/conditions, and weight were the most researched topics. Of the studies included, there was a higher ratio of EOB:BI studies at the MS level. While at the Res level, a lower ratio of EOB:BI was found.

CONCLUSIONS

This study will be of interest to institutions, program directors and medical educators who wish to specifically address a category of bias and identify where there is a dearth of research. This study also underscores the need to introduce bias interventions at the MS level.

Perceptions of healthcare professionals and students about interventions addressing implicit bias and microaggression: A mixed-studies systematic review

AIM

To consolidate and appraise available evidence on the experiences and perceptions of healthcare professionals and students about the interventions addressing implicit bias and microaggression in the clinical setting.

BACKGROUND

Patient-perpetrated acts of implicit bias and microaggression have profound effects on healthcare professionals' and students' mental health. However, the efficacy of interventions targeted at addressing implicit bias and microaggression requires further scrutiny.

DESIGN

Mixed-studies systematic review.

METHODS

A comprehensive search was conducted on PubMed, EMBASE, CINAHL, Scopus, Web of Science, PsycINFO, Cochrane Library, ProQuest (Social Science Premium Collection Database), ProQuest (Dissertations and Theses Global), and ClinicalTrials.gov. Study selection, quality appraisal using the mixed methods appraisal tool, and data extraction were performed. Narrative and thematic synthesis were used to analyze quantitative and qualitative findings respectively. A results-based convergent approach was employed to integrate findings from both research designs.

RESULTS

A total of 23 studies were included, involving 4667 healthcare professionals and students. There were 17 quantitative studies and six mixed-method studies of varying methodological quality. This review presented findings on healthcare professionals' and students' experiences and perceptions of the efficacy of the interventions targeted at addressing implicit bias and microaggression. Two themes were identified: 1) A safe space leading to enhanced confidence, and 2) what and why the interventions worked.

CONCLUSION

Our review findings found that healthcare professionals and students generally had a positive view of implicit bias and microaggression interventions in the realm of helping them gain knowledge and confidence to identify and respond to biased clinical encounters. This review could provide insights for administrators and institutions to provide such interventions in mitigating the impact of implicit bias and microaggression on healthcare staff and students. Future research should focus on comparing the views of participants from varied geographical and cultural backgrounds, and those with different healthcare disciplines.

Implicit bias instruction across disciplines related to the social determinants of health: a scoping review

One criticism of published curricula addressing implicit bias is that few achieve skill development in implicit bias recognition and management (IBRM). To inform the development of skills-based curricula addressing IBRM, we conducted a scoping review of the literature inquiring, "What interventions exist focused on IBRM in professions related to social determinants of health: education, law, social work, and the health professions inclusive of nursing, allied health professions, and medicine?"Authors searched eight databases for articles published from 2000 to 2020. Included studies: (1) described interventions related to implicit bias; and (2) addressed knowledge, attitude and/or skills as outcomes. Excluded were interventions solely focused on reducing/neutralizing implicit bias. Article review for inclusion and data charting occurred independently and in duplicate. Investigators compared characteristics across studies; data charting focused on educational and assessment strategies. Fifty-one full-text articles for data charting and synthesis, with more than 6568 learners, were selected. Educational strategies included provocative/engagement triggers, the Implicit Association Test, reflection and discussion, and various active learning strategies. Most assessments were self-report, with fewer objective measures. Eighteen funded studies utilized federal, foundation, institutional, and private sources. This review adds to the literature by providing tangible examples of curricula to complement existing frameworks, and identifying opportunities for further research in innovative skills-based instruction, learner assessment, and development and validation of outcome metrics. Continued research addressing IBRM would enable learners to develop and practice skills to recognize and manage their implicit biases during clinical encounters, thereby advancing the goal of improved, equitable patient outcomes.

Discovering the Roots: A Qualitative Analysis of Medical Students Exploring Their Unconscious Obesity Bias

Phenomenon: Bias against individuals with obesity in medical settings has negative implications for patients, including stigmatization, poor health outcomes, and reduced healthcare utilization. This study explored reflections of medical students when confronted with their own implicit obesity bias.Approach: A group of 188 pre-clinical second-year medical students from George Washington University School of Medicine and Health Sciences completed the Weight Implicit Association Test (IAT) in 2020 and were instructed to write a reflective response based on their results. Participants reflected upon their preferences ("fat" vs. "thin") and described the factors that influenced their perceptions of obesity. Inductive coding techniques were used to generate themes from medical students' responses using Dedoose Version 8.3.35 (SocioCultural Research Consultants LLC, Los Angeles, California).Findings: Regarding IAT results, 7% of medical students preferred "fat over thin," 14% had no preference, and 78% preferred "thin over fat." Reflection themes highlighted medical students' difficulty accepting IAT results, perspectives on the origins of obesity in individuals, personal and family challenges with obesity and body image, medical training's perceived influence on bias, reservations about discussing obesity with patients, and desires to change current and future practices.Insights: Many medical students expressed a desire to provide optimal care for patients of all weight classes despite demonstrating a strong unconscious bias against individuals with obesity on the IAT. Medical school should provide targeted opportunities to acknowledge and mitigate obesity bias by expanding on medical students' pre-established and often harmful understandings of obesity and highlighting the complexities of this disease. Such training would better equip medical students to facilitate successful interactions with patients as future physicians.

The time is now: addressing implicit bias in obstetrics and gynecology education

Obstetrician-gynecologists can improve the learning environment and patient care by addressing implicit bias. Accumulating evidence demonstrates that racial and gender-based discrimination is woven into medical education, formal curricula, patient-provider-trainee interactions in the clinical workspace, and all aspects of learner assessment. Implicit bias negatively affects learners in every space. Strategies to address implicit bias at the individual, interpersonal, institutional, and structural level to improve the well-being of learners and patients are needed. The authors review an approach to addressing implicit bias in obstetrics and gynecology education, which includes: (1) curricular design using an educational framework of antiracism and social justice theories, (2) bias awareness and management pedagogy throughout the curriculum, (3) elimination of stereotypical patient descriptions from syllabi and examination questions, and (4) critical review of epidemiology and evidence-based medicine for underlying assumptions based on discriminatory practices or structural racism that unintentionally reinforce stereotypes and bias. The movement toward competency-based medical education and holistic evaluations may result in decreased bias in learner assessment. Educators may wish to monitor grades and narratives for bias as a form of continuous educational equity improvement. Given that practicing physicians may have little training in this area, faculty development efforts in bias awareness and mitigation strategies may have significant impact on learner well-being.

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.

Educational strategies used to improve the knowledge, skills, and attitudes of health care students and providers regarding implicit bias: An integrative review of the literature

Background

The thoughts, feelings, and attitudes health care professionals unconsciously have about patients can negatively impact patients' health outcomes. Systematic reviews related to implicit bias in health care providers have uncovered negative implicit bias towards older adults, people of color, people with disabilities, psychiatric patients, patients who are obese, people of low socioeconomic status, and women. Implicit bias impacts the quality, safety, and competence of care delivered; interactions between patients and providers; and patient approval of treatment recommendations. Health care professions students and health care providers need to participate in evidence-based educational strategies to manage and diminish bias.

Objective

To review the evidence regarding educational strategies used with health care professions students and providers to improve their knowledge of implicit bias, reduce bias, and improve attitudes about bias.

Design

Integrative review.

Methods

The literature review was completed in July 2020 with two updates performed in February 2021 and June 2021 using nine databases including Academic Search Complete™, Embase®, ERIC®, Ovid, PubMed®, Scopus®, and Web of Science™. Key terms used related to education, health care professions' students, health care providers, implicit, bias, incivility, microaggression, and microassult. Publications dates from 2011 to 2021 were included. Covidence software was used for the initial screening and for full-text analysis.

Results

Thirty-nine articles were analysed for this review. The most commonly used educational strategies to instruct about principles of implicit bias include discussion groups, simulation and case-based learning, pre-tests for awareness, use of expert facilitators, commitment to action/change, and debriefing. Common components of successful strategies include thoughtful program planning, careful selection of program facilitators (who are content experts), support of participants, and a system-level investment.

Conclusions

Diverse educational strategies successfully addressed implicit bias across studies. Recommendations for future studies includes addressing limitations in sampling strategies and data collection to clarify relationships between educational strategies and participant outcomes. Educational opportunities are warranted that challenge health care professionals to explore their implicit bias towards others in an effort to provide care that considers diversity, equity, and inclusion and also limits personal implicit bias.

Longitudinal outcomes one year following implicit bias training in medical students

PURPOSE

Training in implicit bias is broadly recognized as important in medical education and is mandated by some accrediting bodies. This study examined medical students' retention of concepts immediately following and one-year post participation in an implicit bias workshop.

METHODS

Study subjects were 272 third-year medical students who participated in workshops held between 2018-2020 that used the Implicit Associations Test (IAT) as a trigger for discussions in small groups. We developed a survey and administered it to students to capture their awareness of implicit bias pre-, post-, and one-year post-workshop attendance. Repeated Measures Analyses and independent-samples t-tests were used to examine for differences in responses on each of the seven survey items and a tabulated 7-item average of these seven items.

RESULTS

Six of seven survey items and the tabulated 7-item average examined by Repeated Measures Analyses showed statistically significant increases between the pre-, post-, and one-year post-surveys (ps range: 0.01-0.07), with a small to moderate effect sizes (ƞ_p²s range: 0.01-0.07). Pairwise comparisons among these three surveys' results indicated statistically significant improvements between the pre- and the post-workshop surveys (ps range: 0.01-0.03) but no statistically significant differences between the post- and the one-year post-workshop surveys (ps range: 0.57-0.99). A separate sample of 17 off-cycle students who took the one-year post- workshop survey two years after the workshop did not differ statistically on the level of awareness of bias compared to those taking the same survey one year later, as examined by the two-group independent t-tests for the seven one-year post-workshop survey items (ps range: 0.56-0.99).

CONCLUSIONS

The findings support one-year retention of knowledge and attitudes gained from an implicit bias workshop and suggest similar retention at two years. Future educational interventions that train learners to recognize and manage implicit and explicit behaviors in clinical practice are needed.

Dataset: Knowledge and attitude retention following an implicit bias classroom workshop

Background: Baylor College of Medicine provides a classroom-based implicit bias workshop to all third-year medical students to increase students’ awareness of their unconscious bias and develop strategies for reducing health care disparities. The workshop meets our immediate goals and objectives. However, we are unsure if the benefit would be long-term or diminish over time.

Methods: To examine the concept retention from the implicit bias classroom workshop, we administered a self-developed seven-item seven-point Likert-scale survey to our medical students at pre-, post-, and one-year post-workshop attendance.

Results: The data set was comprised of survey results from two cohorts of our third and fourth-year medical students from 2018 to 2020 and included 289 completed records at three measurement points. The data included: Student Identifiers, Sex, Race/Ethnicity, Student Enrollment Type, Cohort, and three repeated measures results for each of the seven items, which were documented in wide format. The data may be of interest to those who wish to examine how factors including elapsed time, race, and sex may associate with attitudes and understandings of implicit bias following related training, and those interested in analytical methods on longitudinal research in general.

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.

Barriers to Working with Patients Who Misuse Opioids and Physician Burnout: Implications for Medical Education

BACKGROUND

Physicians are on the front lines of the U.S. opioid epidemic, providing care in multiple treatment settings. Very little is known, however, about whether this experience has contributed to physician burnout. This information is critical for guiding efforts to expand the relatively low level of training on opioid misuse currently available in medical education.

METHODS

We surveyed 408 board-certified physicians practicing in Ohio about their experiences working with patients who misuse opioids. We also collected quantitative measures of physicians' burnout and their level of contact with this patient population. We coded and analyzed open-ended responses and calculated a partial correlation between contact and burnout, controlling for relevant factors.

RESULTS

Physicians experienced three primary barriers when working with patients who misuse opioids: inadequate knowledge and training, limited external resources and partnerships in their communities, and an incomplete context for understanding problematic patient behaviors. 70% of physicians experienced negative emotions when working with this patient population and 19% mentioned experiencing burnout specifically. Contact with patients who misuse opioids was significantly and positively associated with burnout scores.

CONCLUSIONS

Our findings underscore the need for medical educators to take a proactive approach to equipping physicians with the knowledge, skills, and resources needed to effectively work with patients who misuse opioids.

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.

Preferring patient-physician concordance: the ambiguity of implicit ethnic bias

BACKGROUND

Much of the current literature on racial/ethnic bias in healthcare focuses on practitioners' implicit biased attitudes regarding patients, identifying it as a factor contributing to health disparities. Little attention has been paid, however, to patients' bias against practitioners from other ethnic group.

AIM

To explore patients' bias towards practitioners from other ethnic group.

METHOD

In-depth interviews were conducted during 2018 with 38 Israeli Jewish and Arab patients.

FINDINGS

While many participants (more Jews than Arabs) reported that they perceive medical treatment as neutral and value the physician's professionalism and attitude, others (more Arabs than Jews) attested that they do prefer to be treated by physicians of their own ethnic group. Jewish patients who prefer Jewish physicians described bias against Arab physicians: Feelings of fear and distrust, particularly in light of the conflictual situation in Israel. They also considered Arab physicians less professional than Jewish ones. Arab patients who prefer Arab physicians described their need for culturally and linguistically competent healthcare and praised close informal relations with Arab physicians, contrasting them with past offensive and humiliating experiences with Jewish physicians.

CONCLUSIONS

Findings reveal several factors that impact Jewish and Arab Israeli patients' preference for patient-physician concordance, some of which reflect patients' implicit bias. This phenomenon - together with practitioners' implicit bias against patients - should be recognized as contributing to the ambiguity of ethnic relations in clinical encounters, particularly in conflictual societies.

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.

How Assumptions and Preferences Can Affect Patient Care: An Introduction to Implicit Bias for First-Year Medical Students

INTRODUCTION

Instruction in implicit bias is becoming prevalent across the spectrum of medical training. Little education exists for preclinical students, and guidance for faculty to facilitate such education is minimal. To address these gaps, we designed and delivered a single session for incoming first-year medical students and developed a facilitator training program.

METHODS

One faculty member delivered a 1-hour, multimedia, interactive lecture to all first-year medical students. Students subsequently met in small groups with trained facilitators. Activities included reflection, guided debriefing, and strategy identification to become aware of when they might be making an assumption causing them to jump to a conclusion about someone. The program evaluation consisted of aggregated student strategies and facilitator feedback during postsession debriefs, both analyzed through thematic analysis.

RESULTS

We delivered instruction to 1,098 students. Student strategies resulted in three themes: (1) humility, (2) reflection, and (3) partnering. The postsession debriefs uncovered opportunities to enhance the session. Lessons learned included presenting material to an entire class at once, allowing students to engage in dynamic discussion in the small groups, eliminating anonymous polling in the small groups, and highlighting management of implicit bias as essential to professional development.

DISCUSSION

Our instructional design enabled first-year medical students to identify at least one strategy to use when implicit biases are activated. The large-group session was deliverable by one faculty member, and volunteers successfully facilitated small-group sessions after only one training session, making this model a feasible innovation to reach an entire medical school class at the same time.

Implicit Bias Recognition and Management: Tailored Instruction for Faculty

BACKGROUND

Implicit bias instruction is becoming more prevalent across the continuum of medical education. Little guidance exists for faculty on recognizing and debriefing about implicit bias during routine clinical encounters.

OBJECTIVE

To assess the impact and feasibility of single seminars on implicit bias and the approach to its management in clinical settings.

METHODS

Between September 2016 and November 2017, the authors delivered five departmental/divisional grand rounds across three different academic medical centers in New York, USA. Instruction provided background information on implicit bias, highlighted its relevance to clinical care, and discussed proposed interventions. To evaluate the impact of instruction participants completed a twelve-item retrospective pre-intervention/post-intervention survey. Questions related to comfort and confidence in recognizing and managing implicit bias, debriefing with learners, and role-modeling behaviors. Participants identified strategies for recognizing and managing potentially biased events through free text prompts. Authors qualitatively analyzed participants' identified strategies.

RESULTS

We received 116 completed surveys from 203 participants (57% response rate). Participants self-reported confidence and comfort increased for all questions. Qualitative analysis resulted in three themes: looking inward, looking outward, and taking action at individual and institutional levels.

CONCLUSION

After a single session, respondents reported increased confidence and comfort with the topic. They identified strategies relevant to their professional contexts which can inform future skills-based interventions. For healthcare organizations responding to calls for implicit bias training, this approach has great promise. It is feasible and can reach a wide audience through usual grand rounds programming, serving as an effective early step in such training.

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.

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.

Defeating Unconscious Bias: The Role of a Structured, Reflective, and Interactive Workshop

BACKGROUND

Unconscious or implicit biases are universal and detrimental to health care and the learning environment but can be corrected. Historical interventions used the Implicit Association Test (IAT), which may have limitations.

OBJECTIVE

We determined the efficacy of an implicit bias training without using the IAT.

METHODS

From April 2019 to June 2020, a 90-minute educational workshop was attended by students, residents, and faculty. The curriculum included an interactive unconscious biases presentation, videoclips using vignettes to demonstrate workplace impact of unconscious biases with strategies to counter, and reflective group discussions. The evaluation included pre- and postintervention surveys. Participants were shown images of 5 individuals and recorded first impressions regarding trustworthiness and presumed profession to unmask implicit bias.

RESULTS

Of approximately 273 participants, 181 were given the survey, of which 103 (57%) completed it with significant increases from pre- to postintervention assessments for perception scores (28.87 [SEM 0.585] vs 32.73 [0.576], P < .001) and knowledge scores (5.68 [0.191] vs 7.22 [0.157], P < .001). For a White male physician covered in tattoos, only 2% correctly identified him as a physician, and 60% felt he was untrustworthy. For a smiling Black female astronaut, only 13% correctly identified her as an astronaut. For a brooding White male serial killer, 50% found him trustworthy.

CONCLUSIONS

An interactive unconscious bias workshop, performed without the use of an IAT, was associated with increases in perceptions and knowledge regarding implicit biases. The findings also confirmed inaccurate first impression stereotypical assumptions based on ethnicity, outward appearances, couture, and media influences.

Bridging racial differences in the clinical encounter: How implicit bias and stereotype threat contribute to health care disparities in the dermatology clinic

BACKGROUND

Positive interactions that build good relationships between patients and providers demonstrate improved health outcomes for patients. Yet, racial minority patients may not be on an equal footing in having positive interactions. Stereotype threat and implicit bias in clinical medicine negatively affect the quality of care that racial minorities receive. Dermatology, one of the least racially diverse specialties in medicine, further falls short in providing patients with options for race-concordant visits, which are noted to afford improved experiences and outcomes.

OBJECTIVE

This study aimed to analyze implicit bias and stereotype threat in a dermatology clinical scenario with the goal of identifying actions that providers, particularly those that are not racial minorities, can take to improve the quality of the clinical interactions between the minority patient and provider.

METHODS

We illustrate a hypothetical patient visit and identify elements that are susceptible to both stereotype threat and implicit bias. We then develop an action plan that dermatologists can use to combat stereotype threat and implicit bias in the clinical setting.

RESULTS

The details of an action plan to combat the effect of stereotype threat and implicit bias are as follows: 1) Invite practices that increase representation within all aspects of the patient visit (from wall art to mission statements to creating a culture that embraces difference and not just diversity); 2) employ communication techniques targeted to invite and understand the patient perspective; and 3) practice making empathic statements to normalize anxiety and foster connection during the visit.

CONCLUSION

Knowledge of stereotype threat and implicit bias and their sequelae, as well as an understanding of steps that can be taken preemptively to counteract these factors, create opportunities to improve clinical care and patient outcomes in racial minority patients.

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.

Applied Racial/Ethnic Healthcare Disparities Research Using Implicit Measures

Many healthcare disparities studies use the Implicit Association Test (IAT) to assess bias. Despite ongoing controversy around the IAT, its use has enabled researchers to reliably document an association between provider implicit prejudice and provider-to-patient communication (provider communication behaviors and patient reactions to them). Success in documenting such associations is likely due to the outcomes studied, study settings, and data structure unique to racial/ethnic healthcare disparities research. In contrast, there has been little evidence supporting the role of providers' implicit bias in treatment recommendations. Researchers are encouraged to use multiple implicit measures to further investigate how, why, and under what circumstances providers' implicit bias predicts provider-to-patient communication and treatment recommendations. Such efforts will contribute to the advancement of both basic social psychology/social cognition research and applied health disparities research: a better understanding of implicit social cognition and a more comprehensive identification of the sources of widespread racial/ethnic healthcare disparities, respectively.

Implicit Bias in Health Professions: From Recognition to Transformation

Implicit bias recognition and management curricula are offered as an increasingly popular solution to address health disparities and advance equity. Despite growth in the field, approaches to implicit bias instruction are varied and have mixed results. The concept of implicit bias recognition and management is relatively nascent, and discussions related to implicit bias have also evoked critique and controversy. In addition, challenges related to assessment, faculty development, and resistant learners are emerging in the literature. In this context, the authors have reframed implicit bias recognition and management curricula as unique forms of transformative learning that raise critical consciousness in both individuals and clinical learning environments. The authors have proposed transformative learning theory (TLT) as a guide for implementing educational strategies related to implicit bias in health professions. When viewed through the lens of TLT, curricula to recognize and manage implicit biases are positioned as a tool to advance social justice.

Professional decision-making in medicine: Development of a new measure and preliminary evidence of validity

Introduction

This study developed a new Professional Decision-Making in Medicine Measure that assesses the use of effective decision-making strategies: seek help, manage emotions, recognize consequences and rules, and test assumptions and motives. The aim was to develop a content valid measure and obtain initial evidence for construct validity so that the measure could be used in future research or educational assessment.

Methods

Clinical scenario-based items were developed based on a review of the literature and interviews with physicians. For each item, respondents are tasked with selecting two responses (out of six plausible options) that they would choose in that situation. Three of the six options reflect a decision-making strategy; these responses are scored as correct. Data were collected from a sample of 318 fourth-year medical students in the United States. They completed a 16-item version of the measure (Form A) and measures of social desirability, moral disengagement, and professionalism attitudes. Professionalism ratings from clerkships were also obtained. A sub-group (n = 63) completed a second 16-item measure (Form B) to pilot test the instrument, as two test forms are useful for pre-posttest designs.

Results

Scores on the new measure indicated that, on average, participants answered 75% of items correctly. Evidence for construct validity included the lack of correlation between scores on the measure and socially desirable responding, negative correlation with moral disengagement, and modest to low correlations with professionalism attitudes. A positive correlation was observed with a clerkship rating focused on professionalism in peer interactions.

Conclusions

These findings demonstrate modest proficiency in the use of decision-making strategies among fourth-year medical students. Additional research using the Professional Decision-Making Measure should explore scores among physicians in various career stages, and the causes and correlates of scores. Educators could utilize the measure to assess courses that teach decision-making strategies.

Does diversity go beyond sex and gender? Gender as social category of diversity training in health profession education - a scoping review

Background: Sex and gender are social categories of diversity. Diversity can be perceived with an intersectional framework as it demonstrates the intersecting categories that might contribute to oppression, inequality, power and privilege. This article focused on what aspects were considered in diversity training programmes for health professions and the role of sex/gender in this context. Method: This scoping review focuses on the social categories mentioned in diversity education of health professionals. Articles on diversity training for health professionals were searched for in the Web of Science database using the keywords gender, diversity, training, education and health professions. Twelve articles were finally included in this review. Thematic analysis was employed to summarise information deduced from articles. Findings: Gaps in the aspects included in diversity training were identified. Findings show that culture was mostly discussed, whereas sex/gender and lesbian, gay, bisexual, transgender, queer and intersex (LGBTQI) were focused on only to a minor extent. Cultural diversity training includes self-reflection on one's own culture, whereas a comparable tool for sex/gender and LGBTQI is missing. Additionally, other social categories of diversity, such as disability or age, are largely absent. Conclusion: Diversity should be incorporated in its full breadth in health profession education and not fragmented. Additionally, other social categories such as gender might benefit from including self-reflection on these categories in addition to reflecting on the role of power and privilege in order to increase self-awareness for diversity. In this way, othering of the population might be prevented and healthcare can be improved for all.

Testing active learning workshops for reducing implicit stereotyping of Hispanics by majority and minority group medical students

The present research tested if having first year medical students complete active learning workshops would reduce their implicit stereotyping of Hispanics as medically noncompliant. The workshops were tested with 78-majority (White) group, 16-target minority (Hispanic, African-American and American-Indian) group, and 42-non-target minority (Asian-American and foreign born students from East Asia and Southeast Asia) group students in the 2018 and 2021 classes in the American Southwest. Prior to the workshops, students completed an implicit association test (IAT), and then participated in two workshops that covered the psychology of intergroup bias, the role of implicit bias in patient care, and activities for learning six strategies for controlling the implicit stereotyping of patients. The results showed that before the workshops, the level of implicit stereotyping of Hispanics was significant for the majority and non-target minority group students, but it was not significant for the target minority group students. After the workshops, target minority students again showed no bias, and implicit stereotyping was significantly lower for the majority group students, but not for the non-target minority students. The results suggest that the workshops may have been effective for majority group and target minority group students, but that more cultural tailoring of the materials and activities may be necessary to address implicit bias among some minority group medical students.

How Diverse Is Your Universe? An Activity for Students to Reflect on Ethnoracial Diversity During Orientation

Introduction

Physicians' unconscious biases have been linked to health disparities within ethnic and racially diverse communities. Addressing these unconscious biases is difficult but may be ameliorated by raising individuals' awareness of the ethnoracial makeup of their personal and professional networks and reflecting on whether it needs to be expanded while in medical school.

Methods

First- and second-year students were provided with an overview of the ethnoracial makeup of individuals within the state, community, and medical school as a means to reflect on the ethnoracial makeup of their future patient population. Following this overview, students engaged in an activity adapted from the University of Houston, which allowed them to visually represent the ethnoracial diversity within their networks. Written reflections on the adapted activity were collected, analyzed using manifest content analysis, and reported according to themes.

Results

The results indicated that the activity was valuable in helping students visualize their current exposure to ethnoracially diverse individuals (143 of 357 responses [40%]) and reflect on their need to expand the level of ethnoracial diversity in their lives (47 of 357 responses [13%]). Additionally, students provided comments to help improve the activity when used in another institution.

Discussion

Assisting students in raising their awareness of the ethnoracial diversity in their personal and professional networks is a step toward addressing the unconscious biases that emerge in physicians while in clinical practice. This activity, designed to raise students' awareness of ethnoracial diversity, originated in Augusta, Georgia, but can be adapted to any state.

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.

A Qualitative Study of New York Medical Student Views on Implicit Bias Instruction: Implications for Curriculum Development

BACKGROUND

For at least the past two decades, medical educators have worked to improve patient communication and health care delivery to diverse patient populations; despite efforts, patients continue to report prejudice and bias during their clinical encounters. Targeted instruction in implicit bias recognition and management may promote the delivery of equitable care, but students at times resist this instruction. Little guidance exists to overcome this resistance and to engage students in implicit bias instruction; instruction over time could lead to eventual skill development that is necessary to mitigate the influence of implicit bias on clinical practice behaviors.

OBJECTIVE

To explore student perceptions of challenges and opportunities when participating in implicit bias instruction.

APPROACH

We conducted a qualitative study that involved 11 focus groups with medical students across each of the four class years to explore their perceptions of challenges and opportunities related to participating in such instruction. We analyzed transcripts for themes.

KEY RESULTS

Our analysis suggests a range of attitudes toward implicit bias instruction and identifies contextual factors that may influence these attitudes. The themes were (1) resistance; (2) shame; (3) the negative role of the hidden curriculum; and (4) structural barriers to student engagement. Students expressed resistance to implicit bias instruction; some of these attitudes are fueled from concerns of anticipated shame within the learning environment. Participants also indicated that student engagement in implicit bias instruction was influenced by the hidden curriculum and structural barriers.

CONCLUSIONS

These insights can inform future curriculum development efforts. Considerations related to instructional design and programmatic decision-making are highlighted. These considerations for implicit bias instruction may provide useful frameworks for educators looking for opportunities to minimize student resistance and maximize engagement in multi-session instruction in implicit bias recognition and management.

A Best Evidence in Medical Education systematic review to determine the most effective teaching methods that develop reflection in medical students: BEME Guide No. 51

INTRODUCTION

Reflection is thought to be an essential skill for physicians. Although much has been written about it, there is little concurrence about how to best teach reflection in medical education. The aim of this review was to determine: (i) which educational interventions are being used to develop reflection, (ii) how is reflection being assessed, and (iii) what are the most effective interventions.

METHODS

Inclusion criteria comprised: (i) undergraduate medical students, (ii) a teaching intervention to develop reflection, and (iii) assessment of the intervention. A review protocol was developed and nine databases were searched. Screening, data extraction, and analysis procedures were performed in duplicate. Due to the heterogeneity of studies, a narrative synthesis approach was performed for the study analysis.

RESULTS

Twenty-eight studies met the inclusion criteria. The interventions in these studies had at least of two of the following components related to reflection: (i) introduction, (ii) trigger, (iii) writing, (iv) guidelines, (v) small group discussion, (vi) tutor and (vii) feedback. Three validated rubrics were used to assess reflective writing in these studies.

CONCLUSIONS

The strongest evidence from studies in this review indicates that guidelines for, and feedback on, reflective writing improve student reflection.

Striving While Accepting: Exploring the Relationship Between Identity and Implicit Bias Recognition and Management

PURPOSE

Implicit biases worsen outcomes for underserved and marginalized populations. Once health professionals are made aware of their implicit biases, a process ensues where they must reconcile this information with their personal and professional identities. The authors sought to explore how identity influences the process of implicit bias recognition and management.

METHOD

Using constructivist grounded theory, the authors recruited 11 faculty and 10 resident participants working at an academic health science center in Canada. Interviews took place from June to October 2017. Participants took an online version of the mental illness implicit association test (IAT) which provides users with their degree of implicit dangerousness bias toward individuals with either physical or mental illness. Once they completed the IAT, participants were invited to draw a rich picture and interviewed about their picture and experience of taking their IAT. Data were analyzed using constant comparative procedures to develop focused codes and work toward the development of a deeper understanding of relationships among themes.

RESULTS

Once implicit biases were brought into conscious awareness, participants acknowledged vulnerabilities which provoked tension between their personal and professional identities. Participants suggested that they reconcile these tensions through a process described as striving for the ideal while accepting the actual. Relationships were central to the process; however, residents and faculty viewed the role of relationships differently.

CONCLUSIONS

Striving for self-improvement while accepting individual shortcomings may provide a model for addressing implicit bias among health professionals, and relational dynamics appear to influence the process of recognizing and managing biases.

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.

The Impact of Health Equity Coaching on Patient's Perceptions of Cultural Competency and Communication in a Pediatric Emergency Department: An Intervention Design

Purpose

American Indian (AI) children experience significant disparities in health-care access. As a result, they are more likely to use the emergency department (ED) for nonemergent visits than white children. In a recent study, pediatric ED providers have shown an implicit bias for white children over AI children. To combat implicit bias in an ED setting, we created a protocol for training ED providers as health equity coaches.

Methods

The intervention took place during the fall of 2016 and was composed of 4 educational lectures, 6 to 8 hours of service learning in AI communities, and the participant's dissemination of what was learned through formal presentations and informal conversations with other ED staff. We measured the impact of this intervention on the intervention participants with a group interview at the completion of the intervention.

Results

The findings from the group interview provide feedback on what was learned during the intervention, how it impacted providers, and feedback on the structure of the intervention. Overall ED providers reported the intervention improved awareness of their implicit bias and ways to improve communication and care for AI patients. Additional institutional policy and procedural changes are necessary to effectively and sustainably address health disparities affecting AI populations.

Conclusions

The participating providers identified their lack of knowledge regarding AI cultures at the start of the intervention and it became clear that their knowledge, comfort, and relationships with AI communities increased as a result of this intervention.

Patient perspectives on racial and ethnic implicit bias in clinical encounters: Implications for curriculum development

OBJECTIVE

Patients describe feelings of bias and prejudice in clinical encounters; however, their perspectives on restoring the encounter once bias is perceived are not known. Implicit bias has emerged as a target for curricular interventions. In order to inform the design of novel patient-centered curricular interventions, this study explores patients' perceptions of bias, and suggestions for restoring relationships if bias is perceived.

METHODS

The authors conducted bilingual focus groups with purposive sampling of self-identified Black and Latino community members in the US. Data were analyzed using grounded theory.

RESULTS

Ten focus groups (in English (6) and Spanish (4)) with N = 74 participants occurred. Data analysis revealed multiple influences patients' perception of bias in their physician encounters. The theory emerging from the analysis suggests if bias is perceived, the outcome of the encounter can still be positive. A positive or negative outcome depends on whether the physician acknowledges this perceived bias or not, and his or her subsequent actions.

CONCLUSIONS

Participant lived experience and physician behaviors influence perceptions of bias, however clinical relationships can be restored following perceived bias.

PRACTICE IMPLICATIONS

Providers might benefit from skill development in the recognition and acknowledgement of perceived bias in order to restore patient-provider relationships.

Adaptive reinventing: implicit bias and the co-construction of social change

Emerging research on implicit bias recognition and management within health professions describes individually focused educational interventions without considering workplace influences. Workplace learning theories highlight how individual agency and workplace structures dynamically interact to produce change within individuals and learning environments. Promoting awareness of individual biases shaped by clinical learning environments may therefore represent a unique type of workplace learning. We sought to explore how individuals and the workplace learning environment interact once awareness of implicit biases are triggered within learners. In accordance with longitudinal case study methodology and informed by constructivist grounded theory, we conducted multiple longitudinal interviews with physician and nurse participants over 12 months. Our results suggest that implicit bias recognition provokes dissonance among participants leading to frustration, and critical questioning of workplace constraints. Once awareness is triggered, participants began reflecting on their biases and engaging in explicit behavioural changes that influenced the perception of structural changes within the learning environment itself. Collaboration, communication and role modeling within teams appeared to facilitate the process as individual and workplace affordances were gradually transformed. Our findings suggest a potential model for understanding how individual learners adaptively reinvent their role in response to disruptions in their learning environment.

Using Virtual Human Technology to Examine Weight Bias and the Role of Patient Weight on Student Assessment of Pediatric Pain

The purpose of the study was to investigate the influence of weight bias and demographic characteristics on the assessment of pediatric chronic pain. Weight status, race, and sex were manipulated in a series of virtual human (VH) digital images of children. Using a web-based platform, 96 undergraduate students with health care-related majors (e.g., Health Science, Nursing, Biology, and Pre-Medicine) read a clinical vignette and provided five ratings targeting the assessment of each VH child's pain. Students also answered a weight bias questionnaire. Group-based analyses were conducted to determine the influence of the VH child's weight and demographic cues, as well as greater weight bias on assessment ratings. Male and VH children with obesity were rated as more likely to avoid non-preferred activities due to pain compared to female and healthy weight children, respectively (both p < .001). The pain of VH children with obesity was rated as more likely to be influenced by psychological/behavioral issues compared to the pain of healthy weight VH children (p = .022). African American VH children were rated as experiencing significantly greater pain than Caucasian VH children (p = .037). As child weight increased, low weight bias participants felt more sympathy, while high weight bias participants felt less sympathy (p = .002). Also, low weight bias participants showed increased motivation to help, while high weight bias participants showed less motivation to help, as VH patient weight increased (p = .008). Child weight and evaluator weight bias may be influential in the assessment of pediatric pain. If supported by future research, results highlight the importance of training in evidence-based practice and education on weight bias for students majoring in health-care fields.

The Actual Versus Idealized Self: Exploring Responses to Feedback About Implicit Bias in Health Professionals

PURPOSE

Implicit bias can adversely affect health disparities. The implicit association test (IAT) is a prompt to stimulate reflection; however, feedback about bias may trigger emotions that reduce the effectiveness of feedback interventions. Exploring how individuals process feedback about implicit bias may inform bias recognition and management curricula. The authors sought to explore how health professionals perceive the influence of the experience of taking the IAT and receiving their results.

METHOD

Using constructivist grounded theory methodology, the authors conducted semistructured interviews with 21 pediatric physicians and nurses at the Schulich School of Medicine and Dentistry, Western University, Ontario, Canada, from September 2015 to November 2016 after they completed the mental illness IAT and received their result. Data were analyzed using constant comparative procedures to work toward axial coding and development of an explanatory theory.

RESULTS

When provided feedback about their implicit attitudes, participants described tensions between acceptance and justification, and between how IAT results relate to idealized and actual personal and professional identity. Participants acknowledged desire for change while accepting that change is difficult. Most participants described the experience of taking the IAT and receiving their result as positive, neutral, or interesting.

CONCLUSIONS

These findings contribute to emerging understandings of the relationship between emotions and feedback and may offer potential mediators to reconcile feedback that reveals discrepancies between an individual's actual and idealized identities. These results suggest that reflection informed by tensions between actual and aspirational aspects of professional identity may hold potential for implicit bias recognition and management curricula.

Changes in medical student implicit attitudes following a health equity curricular intervention

PURPOSE

This study assessed the: (1) effect of an LGBTQI + health equity curriculum (eQuality) on implicit attitudes among first (M1) and second year (M2) medical students and (2) utility of dedicated time to explore implicit bias.

METHOD

Implicit biases were assessed at baseline using implicit association tests (IAT) for all M2s and a random sample of first years (M1A). These students were then debriefed on strategies to mitigate bias. Following eQuality, all M1 and M2s completed post-intervention IATs. The remaining first years (M1B) were then debriefed. Paired sample t-tests assessed differences between pre/post. Independent sample t-tests assessed differences in post-IATs between M1 groups.

RESULTS

IATs indicated preferences for "Straight," "White," and "Thin" at both pre and post. M2s demonstrated statistically significant improvements pre to post for sexuality (p = 0.01) and race (p = 0.03). There were significant differences in post-intervention IAT scores between M1As who received the IAT and debriefing prior to eQuality and M1Bs for sexuality (p = 0.002) and race (p = 0.046). There were no significant changes for weight.

CONCLUSION

eQuality reduced implicit preference for "Straight" and "White." Differences in M1 post-intervention IAT scores between groups suggest dedicating time to debrief implicit attitudes enhances bias mitigation.

A Framework for Integrating Implicit Bias Recognition Into Health Professions Education

Existing literature on implicit bias is fragmented and comes from a variety of fields like cognitive psychology, business ethics, and higher education, but implicit-bias-informed educational approaches have been underexplored in health professions education and are difficult to evaluate using existing tools. Despite increasing attention to implicit bias recognition and management in health professions education, many programs struggle to meaningfully integrate these topics into curricula. The authors propose a six-point actionable framework for integrating implicit bias recognition and management into health professions education that draws on the work of previous researchers and includes practical tools to guide curriculum developers. The six key features of this framework are creating a safe and nonthreatening learning context, increasing knowledge about the science of implicit bias, emphasizing how implicit bias influences behaviors and patient outcomes, increasing self-awareness of existing implicit biases, improving conscious efforts to overcome implicit bias, and enhancing awareness of how implicit bias influences others. Important considerations for designing implicit-bias-informed curricula-such as individual and contextual variables, as well as formal and informal cultural influences-are discussed. The authors also outline assessment and evaluation approaches that consider outcomes at individual, organizational, community, and societal levels. The proposed framework may facilitate future research and exploration regarding the use of implicit bias in health professions education.