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

Explicit and indirect, latency-based measure of aggression in striking combat sports

Introduction

Aggression in sports is often perceived as a necessary trait for success, especially in martial arts. Aggression can be assessed both explicitly and implicitly, taking into account the dual processing model. The purpose of the research was to examine explicit and indirect, latency-based measure of aggression in competitive athletes practicing striking combat sports, according to gender and sports performance. At the same time, we verified whether aggression (implicit/unconscious and explicit) predicts sports performance in martial artists.

Materials and methods

A total of 85 athletes practicing striking combat sports took part in the research. For implicit, latency-based measure of aggression, an Implicit Associations Test (IAT) was used, while explicit aggression was assessed with the Romanian adaptation of the Makarowski's Aggression Questionnaire for martial arts athletes.

Results

Data analysis revealed (using multivariate analysis of variance) that athletes from striking combat sports having international sports performances registered significantly higher D-scores (IAT, p = 0.014) and lower values for Go-ahead factor (p = 0.006), compared to athletes without outstanding results. Goodman and Kruskal tau association test was used to check the existing associations between athletes' gender and martial arts athletes' level of explicit and implicit aggression. In addition, binomial logistic regression procedures were performed, predicting martial artists' likelihood to obtain higher sports results, based on explicit and indirect aggression.

Conclusion

A stronger association between Aggression and Others (at implicit/unconscious level) and a moderate level (generally) for Go-ahead factor of explicit aggression are associated with an increased likelihood of sports performances in athletes. In addition, male martial arts athletes are more persistent despite obstacles, remaining more on the offensive (no gender-related association were found in terms of indirect/unconscious aggression, and for Foul Play and Assertiveness factors of explicit aggression). The study underlines the importance of addressing athletes' subconscious level to promote more constructive behaviors in competitions.

Addressing Disparities in Pediatric Congenital Heart Disease: A Call for Equitable Health Care

While significant progress has been made in reducing disparities within the US health care system, notable gaps remain. This article explores existing disparities within pediatric congenital heart disease care. Congenital heart disease, the most common birth defect and a leading cause of infant death, has garnered substantial attention, revealing certain disparities within the US health care system. Factors such as race, ethnicity, insurance coverage, socioeconomic status, and geographic location are all commonalities that significantly affect health disparities in pediatric congenital heart disease. This comprehensive review sheds light on disparities from diverse perspectives in pediatric care, demonstrates the inequities and inequalities leading to these disparities, presents effective solutions, and issues a call to action for providers, institutions, and the health care system. Recognizing and addressing these disparities is imperative for ensuring equitable care and enhancing the long-term well-being of children affected by congenital heart disease. Implementing robust, evidence-based frameworks that promote responsible and safe interventions is fundamental to enduring change.

A Shadow of Doubt: Is There Implicit Bias Among Orthopaedic Surgery Faculty and Residents Regarding Race and Gender?

BACKGROUND

Orthopaedic surgery continues to be one of the least diverse medical specialties. Recently, increasing emphasis has been placed on improving diversity in the medical field, which includes the need to better understand existing biases. Despite this, only about 6% of orthopaedic surgeons are women and 0.3% are Black. Addressing diversity, in part, requires a better understanding of existing biases. Most universities and residency programs have statements and policies against discrimination that seek to eliminate explicit biases. However, unconscious biases might negatively impact the selection, training, and career advancement of women and minorities who are underrepresented in orthopaedic surgery. Although this is difficult to measure, the Implicit Association Test (IAT) by Project Implicit might be useful to identify and measure levels of unconscious bias among orthopaedic surgeons, providing opportunities for additional interventions to improve diversity in this field.

QUESTIONS/PURPOSES

(1) Do orthopaedic surgeons demonstrate implicit biases related to race and gender roles? (2) Are certain demographic characteristics (age, gender, race or ethnicity, or geographic location) or program characteristics (geographic location or size of program) associated with the presence of implicit biases? (3) Do the implicit biases of orthopaedic surgeons differ from those of other healthcare providers or the general population?

METHODS

A cross-sectional study of implicit bias among orthopaedic surgeons was performed using the IAT from Project Implicit. The IAT is a computerized test that measures the time required to associate words or pictures with attributes, with faster or slower response times suggesting the ease or difficulty of associating the items. Although concerns have been raised recently about the validity and utility of the IAT, we believed it was the right study instrument to help identify the slight hesitation that can imply differences between inclusion and exclusion of a person. We used two IATs, one for Black and White race and one for gender, career, and family roles. We invited a consortium of researchers from United States and Canadian orthopaedic residency programs. Researchers at 34 programs agreed to distribute the invitation via email to their faculty, residents, and fellows for a total of 1484 invitees. Twenty-eight percent (419) of orthopaedic surgeons and trainees completed the survey. The respondents were 45% (186) residents, 55% (228) faculty, and one fellow. To evaluate response biases, the respondent population was compared with that of the American Academy of Orthopaedic Surgeons census. Responses were reported as D-scores based on response times for associations. D-scores were categorized as showing strong (≥ 0.65), moderate (≥ 0.35 to < 0.65), or slight (≥ 0.15 to < 0.35) associations. For a frame of reference, orthopaedic surgeons' mean IAT scores were compared with historical scores of other self-identified healthcare providers and that of the general population. Mean D-scores were analyzed with the Kruskal-Wallis test to determine whether demographic characteristics were associated with differences in D-scores. Bonferroni correction was applied, and p values less than 0.0056 were considered statistically significant.

RESULTS

Overall, the mean IAT D-scores of orthopaedic surgeons indicated a slight preference for White people (0.29 ± 0.4) and a slight association of men with career (0.24 ± 0.3), with a normal distribution. Hence, most respondents' scores indicated slight preferences, but strong preferences for White race were noted in 27% (112 of 419) of respondents. There was a strong association of women with family and home and an association of men with work or career in 14% (60 of 419). These preferences generally did not correlate with the demographic, geographic, and program variables that were analyzed, except for a stronger association of women with family and home among women respondents. There were no differences in race IAT D-scores between orthopaedic surgeons and other healthcare providers and the general population. Gender-career IAT D-scores associating women with family and home were slightly lower among orthopaedic surgeons (0.24 ± 0.3) than among the general population (0.32 ± 0.4; p < 0.001) and other healthcare professionals (0.34 ± 0.4; p < 0.001). All of these values are in the slight preference range.

CONCLUSION

Orthopaedic surgeons demonstrated slight preferences for White people, and there was a tendency to associate women with career and family on IATs, regardless of demographic and program characteristics, similar to others in healthcare and the general population. Given the similarity of scores with those in other, more diverse areas of medicine, unconscious biases alone do not explain the relative lack of diversity in orthopaedic surgery.

CLINICAL RELEVANCE

Implicit biases only explain a small portion of the lack of progress in improving diversity, equity, inclusion, and belonging in our workforce and resolving healthcare disparities. Other causes including explicit biases, an unwelcoming culture, and perceptions of our specialty should be examined. Remedies including engagement of students and mentorship throughout training and early career should be sought.

A Comparative Review of Oral Board Delivery Across Procedural Disciplines

OBJECTIVE

Despite its ubiquity in the certification process among surgical specialties, there is little data regarding oral board delivery across various procedural fields. In this study we sought to determine the specifics of oral board exam administration across surgical disciplines with the goal of highlighting common practices, differences, and areas of innovation. This comparative analysis might further serve to identify unifying principles that undergird the oral board examination process across specialties.

DESIGN

A standardized questionnaire was developed that included domains of exam structure/administration, content development, exam prerequisites, information about examiners, scoring, pass/failure rates, and emerging technologies. Between December 2022 and February 2023 structured interviews were conducted to discuss specifics of various oral board exams. Interview answers were compared between various specialties to extrapolate themes and to highlight innovative or emerging techniques among individual boards.

SETTING

Interviews were conducted virtually.

PARTICIPANTS

Executive members of 9 procedural medical boards including anesthesiology, neurosurgery, obstetrics, and gynecology, ophthalmology, orthopaedic surgery, otolaryngology-head and neck surgery, plastic surgery, general surgery, and urology RESULTS: Common themes include assessment of pre-, intra- and postoperative care; all testing involved candidate examination by multiple examiners and psychometricians were used by all organizations. Important differences included virtual versus in person administration (3 out of 9), inclusion and discussion of candidates' case logs as part of the exam (4 out of 9), formal assessment of professionalism (4 out of 9), and inclusion of an objective structured clinical examination (2 out of 9).

CONCLUSIONS

While there are common themes and practices in the oral board delivery process between various surgical fields, and important differences continue to exist. Ongoing efforts to standardize exam administration and determine best practices are needed to ensure oral board exams continue to effectively establish that candidates meet the qualifications required for board certification.

Examining Linguistic Differences in Electronic Health Records for Diverse Patients With Diabetes: Natural Language Processing Analysis

Background

Individuals from minoritized racial and ethnic backgrounds experience pernicious and pervasive health disparities that have emerged, in part, from clinician bias.

Objective

We used a natural language processing approach to examine whether linguistic markers in electronic health record (EHR) notes differ based on the race and ethnicity of the patient. To validate this methodological approach, we also assessed the extent to which clinicians perceive linguistic markers to be indicative of bias.

Methods

In this cross-sectional study, we extracted EHR notes for patients who were aged 18 years or older; had more than 5 years of diabetes diagnosis codes; and received care between 2006 and 2014 from family physicians, general internists, or endocrinologists practicing in an urban, academic network of clinics. The race and ethnicity of patients were defined as White non-Hispanic, Black non-Hispanic, or Hispanic or Latino. We hypothesized that Sentiment Analysis and Social Cognition Engine (SEANCE) components (ie, negative adjectives, positive adjectives, joy words, fear and disgust words, politics words, respect words, trust verbs, and well-being words) and mean word count would be indicators of bias if racial differences emerged. We performed linear mixed effects analyses to examine the relationship between the outcomes of interest (the SEANCE components and word count) and patient race and ethnicity, controlling for patient age. To validate this approach, we asked clinicians to indicate the extent to which they thought variation in the use of SEANCE language domains for different racial and ethnic groups was reflective of bias in EHR notes.

Results

We examined EHR notes (n=12,905) of Black non-Hispanic, White non-Hispanic, and Hispanic or Latino patients (n=1562), who were seen by 281 physicians. A total of 27 clinicians participated in the validation study. In terms of bias, participants rated negative adjectives as 8.63 (SD 2.06), fear and disgust words as 8.11 (SD 2.15), and positive adjectives as 7.93 (SD 2.46) on a scale of 1 to 10, with 10 being extremely indicative of bias. Notes for Black non-Hispanic patients contained significantly more negative adjectives (coefficient 0.07, SE 0.02) and significantly more fear and disgust words (coefficient 0.007, SE 0.002) than those for White non-Hispanic patients. The notes for Hispanic or Latino patients included significantly fewer positive adjectives (coefficient -0.02, SE 0.007), trust verbs (coefficient -0.009, SE 0.004), and joy words (coefficient -0.03, SE 0.01) than those for White non-Hispanic patients.

Conclusions

This approach may enable physicians and researchers to identify and mitigate bias in medical interactions, with the goal of reducing health disparities stemming from bias.

Dear Program Director: An Evaluation of Implicit Bias in Letters of Recommendation for Neurosurgery Residency

BACKGROUND AND OBJECTIVES

Despite comprising half of medical students, women represent only 29.6% of neurosurgery applicants and 17% of residents, suggesting a "leak" in the career pipeline for women neurosurgeons. Surveys persistently show that neurosurgery programs identify United States Medical Licensing Examination (USMLE®) Step 1 score and letters of recommendation (LORs) as the most important factors in selecting applicants to interview. A previous study in neurosurgery found no differences in LORs. However, multiple studies in other specialties have demonstrated implicit gender bias in LORs, which may influence resident selection. Our objective is to evaluate neurosurgery residency LORs for evidence of implicit gender bias.

METHODS

Retrospective analysis of LORs for interviewed neurosurgery applicants at a single institution during the 2014 to 2020 National Residency Matching Program (NRMP®) match cycles. Letters were evaluated using Linguistic Inquiry & Word Count (LIWC) software (Pennebaker Conglomerates), and additional applicant data were obtained from candidate applications. LIWC (Pennebaker Conglomerates) output data included custom dictionary categories and terms that were analyzed using Prism 10 and Rstudio.

RESULTS

Two hundred eighteen applications were reviewed for a total of 827 letters. LIWC (Pennebaker Conglomerates) analysis showed significant differences in word count (331 vs 297, difference = 34, 95% CI: 9-61, P = .008). LORs for applicants who were men were more likely to mention Alpha Omega Alpha Honor Medical Society (1.17 vs 0.778, difference = 0.4, 95% CI: 0.13-0.67, P = .023). USMLE® Step 1 scores were significantly lower for women (241 vs 247, difference = 6, 95% CI: 2-10, P = .004). There was no significant difference between letters for men and women for all categories evaluated in the linguistic evaluation.

CONCLUSION

LORs are vital to the neurosurgical residency application process. The data exhibit some differences between the men and women applicants but few differences in their LORs, consistent with the results of the previous neurosurgical study.

Promoting Equity, Diversity, and Inclusion in Medicine: A Comprehensive Toolkit for Change in Radiology

This toolkit presents a comprehensive framework for a toolkit intended to increase equity, diversity, and inclusion (EDI) within the medical field and recommendations. We advocate for clear, comprehensive definitions and interpretations of fundamental EDI terms, laying the groundwork necessary for initiating and maintaining EDI initiatives. Furthermore, we offer a systematic approach to establishing EDI committees within medical departments, accentuating the pivotal role these committees play as they drive and steer EDI strategies. This toolkit also explores strategies tailored for the recruitment of a diverse workforce. This includes integral aspects such as developing inclusive job advertisements, implementing balanced search methods for candidates, conducting unbiased appraisals of applications, and structuring diverse hiring committees. The emphasis on these strategies not only augments the diversity within medical institutions but also sets the stage for a more holistic approach to healthcare delivery. Therefore, by adopting the recommended strategies and guidelines outlined in this framework, medical institutions and specifically radiology departments can foster an environment that embodies inclusivity and equity, thereby enhancing the quality of patient care and overall health outcomes.

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.

Addressing the Elephant in the Room: Perceptions and Treatment of Underrepresented in Medicine Physician Assistants/Associate Educators

ABSTRACT

On Thursday, June 27, 2023, the US Supreme Court struck down race-conscious admission practices in higher education. While other demographic factors, such as the traditional Health Resources and Services Administration-disadvantaged background indicators, can be considered during the holistic admission process, explicit consideration based on race and/or ethnicity is prohibited. As a result, physician assistant/associate (PA) programs are tasked with developing novel ways to address equity, diversity, and inclusion during the admission and hiring processes. As Drumgold et al note, closing the PA workforce diversity gap is necessary to achieve health equity. Despite this, PA programs consistently struggle to attract and retain underrepresented in medicine (URiM) faculty, staff, and students. The latest PA Education Association Student Report indicates that more than 75% of applicants consider faculty and student body diversity when applying to programs. As such, addressing disparities in the recruitment, promotion, evaluation, and retention of URiM faculty is paramount. Here, the authors outline ongoing recruitment and retention challenges for URiM faculty along with institutional recommendations to ensure URiM PA faculty success and engagement.

Raising Cultural Awareness and Addressing Barriers to Breast Imaging Care for Black Women

Health care disparities, which are differences in the attainment of full health potential among population groups, have been documented across medical conditions, clinical settings, and diagnostic and treatment modalities. Deeply rooted health care disparities due to many factors have affected how Black women (BW) view medical care including screening mammography. This article explores health care disparities around breast cancer in BW and how patient distrust, provider biases, race, and social determinants of health continue to have negative effects on breast cancer outcomes in BW, despite medical advances in breast cancer detection and management. In addition, this article addresses the importance of culturally competent care for BW around breast cancer awareness, screening, and treatment, and offers strategies to address disparities and rebuild trust.

Implicit Bias Toward Lesbian and Gay Persons Among Nursing Students: A Correlation Study

AIM

The purpose of this study was to measure implicit bias among nursing students toward lesbian and gay (LG) persons.

BACKGROUND

Implicit bias is identified as a contributor to the health disparities experienced by LG persons. This bias has not been studied among nursing students.

METHOD

This descriptive, correlation study used the Implicit Association Test to measure implicit bias in a convenience sample of baccalaureate nursing students. Demographic information was collected to identify relevant predictor variables.

RESULTS

Implicit bias in this sample ( n = 1,348) favored straight persons over LG persons ( D -score = 0.22). Participants identifying as male ( B = 0.19), straight ( B = 0.65), other sexuality ( B = 0.33), somewhat ( B = 0.09) or very religious ( B = 0.14), or enrollment in an RN-BSN program ( B = 0.11) predicted stronger bias favoring straight persons.

CONCLUSION

Implicit bias toward LG persons among nursing students remains a challenge for educators.

CE: Reducing Bias Against People with Substance Use Disorders

ABSTRACT

Addiction is a highly misunderstood and stigmatized chronic illness frequently encountered by health care providers during routine medical care. People with substance use disorders, in particular, face extraordinary stigma and bias when interacting with health care providers, including nurses. Stigma associated with addiction contributes to health inequities and is recognized as a significant barrier to people seeking and receiving necessary health care. Since patients often spend the most time with nurses in the clinical setting, nurses are ideally positioned to address addiction stigma. However, many nurses lack knowledge about addiction, stigma, and the impact of the words they use, whether in conversation or in clinical documentation. This article reviews the consequences of addiction stigma (labeling, stereotyping, or discrimination) and the steps nurses can take to reduce biases related to substance use. A case scenario based on our experience will be used to guide a discussion of opportunities for nurses to intervene and improve care.

Effective Mentoring Across Differences-Best Practices and Effective Models to Address the Needs of Underrepresented Trainees in Surgical Residency Programs

BACKGROUND

Mentorship plays a critical role in the career development of surgical trainees and faculty. As the surgical workforce continues to diversify, mentoring trainees who differ) race, ethnicity, country of origin, socioeconomic status, educational background, religion, gender, sexual orientation or ability) can pose challenges to the experience for both mentor and mentee.

OBJECTIVE

The aim of this manuscript is to introduce surgical educators to the systemic barriers faced by trainees and to models of effective mentorship.

METHODS

At the 2022 APDS Meeting, a panel convened to highlight the current challenges of mentoring across differences and effective models for surgical educators. This paper highlights and expands the summary of this panel.

RESULTS

Examples of novel mentoring models are described.

CONCLUSIONS

Acknowledgment of barriers, Implementation of deliberate mentoring strategies, and collaboration with national surgical organizations and surgery departments and faculty may help to reduce physician attrition.

Educational strategies in the health professions to mitigate cognitive and implicit bias impact on decision making: a scoping review

BACKGROUND

Cognitive and implicit biases negatively impact clinicians' decision-making capacity and can have devastating consequences for safe, effective, and equitable healthcare provision. Internationally, health care clinicians play a critical role in identifying and overcoming these biases. To be workforce ready, it is important that educators proactively prepare all pre-registration healthcare students for real world practice. However, it is unknown how and to what extent health professional educators incorporate bias training into curricula. To address this gap, this scoping review aims to explore what approaches to teaching cognitive and implicit bias, for entry to practice students, have been studied, and what are the evidence gaps that remain.

METHODS

This scoping review was guided by the Joanna Briggs Institute (JBI) methodology. Databases were searched in May 2022 and included CINAHL, Cochrane, JBI, Medline, ERIC, Embase, and PsycINFO. The Population, Concept and Context framework was used to guide keyword and index terms used for search criteria and data extraction by two independent reviewers. Quantitative and qualitative studies published in English exploring pedagogical approaches and/or educational techniques, strategies, teaching tools to reduce the influence of bias in health clinicians' decision making were sought to be included in this review. Results are presented numerically and thematically in a table accompanied by a narrative summary.

RESULTS

Of the 732 articles identified, 13 met the aim of this study. Most publications originated from the United States (n=9). Educational practice in medicine accounted for most studies (n=8), followed by nursing and midwifery (n=2). A guiding philosophy or conceptual framework for content development was not indicated in most papers. Educational content was mainly provided via face-to-face (lecture/tutorial) delivery (n=10). Reflection was the most common strategy used for assessment of learning (n=6). Cognitive biases were mainly taught in a single session (n=5); implicit biases were taught via a mix of single (n=4) and multiple sessions (n=4).

CONCLUSIONS

A range of pedagogical strategies were employed; most commonly, these were face-to-face, class-based activities such as lectures and tutorials. Assessments of student learning were primarily based on tests and personal reflection. There was limited use of real-world settings to educate students about or build skills in biases and their mitigation. There may be a valuable opportunity in exploring approaches to building these skills in the real-world settings that will be the workplaces of our future healthcare workers.

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.

Examining Implicit Biases of Pre-Service Educators Within a Professional Development Context

The opportunity gap, or conditions and barriers that impede the academic performance and school experience of minoritized students, may be exacerbated by educators' implicit biases. The aim of this qualitative study was to understand preservice educators' awareness of individual, structural, and systemic racism with regard to implicit bias. Our sample included 154 preservice educators, enrolled in an anti-bullying/harassment/discrimination training, which is required for any New York State (NYS) educator certification. Educators responded to questions about group generalizations, factors contributing to these biases, and how biases may affect their behavior toward students. Our content analysis revealed several themes, most notably that frequent biases existed toward Asian/Asian Americans, Black/African Americans, males, and people from socioeconomically disadvantaged backgrounds. Although participant responses reflect an open-minded approach to discussing bias, many responses reflected no observable desire to change potentially biased interactions with students. Responses with racially held biases aligned with the tenets of critical race theory (CRT), particularly racism as permanent and racism as normalized. Implications for practice, with an emphasis on anti-bias training and professional development, are discussed.

Prevalence and characteristics of anti-Indigenous bias among Albertan physicians: a cross-sectional survey and framework analysis

OBJECTIVE

Recent deaths of Indigenous patients in the Canadian healthcare system have been attributed to structural and interpersonal racism. Experiences of interpersonal racism by Indigenous physicians and patients have been well characterised, but the source of this interpersonal bias has not been as well studied. The aim of this study was to describe the prevalence of explicit and implicit interpersonal anti-Indigenous biases among Albertan physicians.

DESIGN AND SETTING

This cross-sectional survey measuring demographic information and explicit and implicit anti-Indigenous biases was distributed in September 2020 to all practising physicians in Alberta, Canada.

PARTICIPANTS

375 practising physicians with an active medical licence.

OUTCOMES

Explicit anti-Indigenous bias, measured by two feeling thermometer methods: participants slid an indicator on a thermometer to indicate their preference for white people (full preference is scored 100) or Indigenous people (full preference, 0), and then participants indicated how favourably they felt toward Indigenous people (100, maximally favourable; 0, maximally unfavourable). Implicit bias was measured using an Indigenous-European implicit association test (negative scores suggest preference for European (white) faces). Kruskal-Wallis and Wilcoxon rank-sum tests were used to compare bias across physician demographics, including intersectional identities of race and gender identity.

MAIN RESULTS

Most of the 375 participants were white cisgender women (40.3%; n=151). The median age of participants was 46-50 years. 8.3% of participants felt unfavourably toward Indigenous people (n=32 of 375) and 25.0% preferred white people to Indigenous people (n=32 of 128). Median scores did not differ by gender identity, race or intersectional identities. White cisgender men physicians had the greatest implicit preferences compared with other groups (-0.59 (IQR -0.86 to -0.25); n=53; p<0.001). Free-text responses discussed 'reverse racism' and expressed discomfort with survey questions addressing bias and racism.

CONCLUSIONS

Explicit anti-Indigenous bias was present among Albertan physicians. Concerns about 'reverse racism' targeting white people and discomfort discussing racism may act as barriers to addressing these biases. About two-thirds of respondents had implicit anti-Indigenous bias. These results corroborate the validity of patient reports of anti-Indigenous bias in healthcare and emphasise the need for effective intervention.

Using Simulation-Based Learning with Standardized Patients (SP) in an Implicit Bias Mitigation Clinician Training Program

Objectives

To describe the development and refinement of an implicit bias recognition and management training program for clinical trainees.

Methods

In the context of an NIH-funded clinical trial to address healthcare disparities in hypertension management, research and education faculty at an academic medical center used a participatory action research approach to engage local community members to develop and refine a "knowledge, awareness, and skill-building" bias recognition and mitigation program. The program targeted medical residents and Doctor of Nursing Practice students. The content of the two-session training included: didactics about healthcare disparities, racism and implicit bias; implicit association test (IAT) administration to raise awareness of personal implicit bias; skill building for bias-mitigating communication; and case scenarios for skill practice in simulation-based encounters with standardized patients (SPs) from the local community.

Results

The initial trial year enrolled n  =  65 interprofessional participants. Community partners and SPs who engaged throughout the design and implementation process reported overall positive experiences, but SPs expressed need for greater faculty support during in-person debriefings following simulation encounters to balance power dynamics. Initial year trainee participants reported discomfort with intensive sequencing of in-person didactics, IATs, and SP simulations in each of the two training sessions. In response, authors refined the training program to separate didactic sessions from IAT administration and SP simulations, and to increase safe space, and trainee and SP empowerment. The final program includes more interactive discussions focused on identity, race and ethnicity, and strategies to address local health system challenges related to structural racism.

Conclusion

It is possible to develop and implement a bias awareness and mitigation skills training program that uses simulation-based learning with SPs, and to engage with local community members to tailor the content to address the experience of local patient populations. Further research is needed to measure the success and impact of replicating this approach elsewhere.

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.

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.

Anti-Indigenous bias of medical school applicants: a cross-sectional study

BACKGROUND

Structural and interpersonal anti-Indigenous racism is prevalent in Canadian healthcare. The Truth and Reconciliation Commission calls on medical schools to address anti-Indigenous bias in students. We measured the prevalence of interpersonal anti-Indigenous bias among medical school applicants to understand how the medical school selection process selects for or against students with high levels of bias.

METHODS

All applicants to a single university in the 2020-2021 admissions cycle were invited to participate. Explicit anti-Indigenous bias was measured using two sliding scale thermometers. The first asked how participants felt about Indigenous people (from 0, indicating 'cold/unfavourable' to 100, indicating 'warm/favourable') and the second asked whether participants preferred white (scored 100) or Indigenous people (scored 0). Participants then completed an implicit association test examining preferences for European or Indigenous faces (negative time latencies suggest preference for European faces). Explicit and implicit anti-Indigenous biases were compared by applicant demographics (including gender and racial identity), application status (offered an interview, offered admission, accepted a position), and compared to undergraduate medical and mathematics students.

RESULTS

There were 595 applicant respondents (32.4% response rate, 64.2% cisgender women, 55.3% white). Applicants felt warmly toward Indigenous people (median 96 (IQR 80-100)), had no explicit preference for white or Indigenous people (median 50 (IQR 37-55), and had mild implicit preference for European faces (- 0.22 ms (IQR -0.54, 0.08 ms)). There were demographic differences associated with measures of explicit and implicit bias. Applicants who were offered admission had warmer feelings toward Indigenous people and greater preference for Indigenous people compared to those were not successful.

CONCLUSIONS

Medical school applicants did not have strong interpersonal explicit and implicit anti-Indigenous biases. Outlier participants with strong biases were not offered interviews or admission to medical school.

Assumptions about patients seeking PrEP: Exploring the effects of patient and sexual partner race and gender identity and the moderating role of implicit racism

Introduction

Daily pre-exposure prophylaxis (PrEP) for HIV-prevention is an essential component of national plans to end the HIV epidemic. Despite its well-documented safety and effectiveness, PrEP prescription has not met the public health need. Significant disparities between White and Black people exist with respect to PrEP prescription, as do disparities between men and women. One factor contributing to these disparities is clinicians’ assumptions about patients seeking PrEP.

Methods

The present study sought to investigate medical students’ assumptions about patients seeking PrEP (anticipated increased condomless sex, extra-relational sex, and adherence to PrEP), and assumed HIV risk when presenting with their sexual partner. We systematically varied the race (Black or White) and gender (man or woman) of a fictional patient and their sexual partner. All were in serodifferent relationships including men who have sex with men (MSM), women (MSW), and women who have sex with men (WSM). Participants also completed an implicit association test measuring implicit racism against Black people. We evaluated the moderation effects of patient and partner race on assumptions as well as the moderated moderation effects of implicit racism.

Results

A total of 1,472 students participated. For MSM patients, having a Black partner was associated with higher assumed patient non-adherence to PrEP compared to a White partner, however a White partner was associated with higher assumed HIV risk. For MSW patients, a White male patient was viewed as being more likely to engage in more extra-relational sex compared to a Black male patient. For WSM patients, White women were assumed to be more likely to have condomless and extra-relational sex, be nonadherent to PrEP, and were at higher HIV risk. Overall, implicit racism was not related to negative assumptions about Black patients as compared to White patients based on patient/partner race.

Discussion

Medical education about PrEP for HIV prevention must ensure future health professionals understand the full range of patients who are at risk for HIV, as well as how implicit racial biases may affect assumptions about patients in serodifferent couples seeking PrEP for HIV prevention. As gatekeepers for PrEP prescription, clinicians’ assumptions about patients seeking PrEP represent a barrier to access. Consistent with prior research, we identified minimal effects of race and implicit racism in an experimental setting.

Strategies to Promote Racial Healthcare Equity in Pain Medicine: A Call to Action

In the past several years, many national events have illuminated the inequities faced by the Black community in all aspects of life, including healthcare. To close the gap in healthcare equity, it is imperative that clinicians examine their practices for disparities in the treatment of minority patients and for racial injustice and take responsibility for improving any issues. As leaders in pain medicine, we can start by improving our understanding of healthcare disparities and inequities among racial and ethnic minorities and translating that knowledge into a cultural transformation to improve the care of those impacted. In this paper, we identify the areas of medicine in which pain assessment and treatment are not equitably delivered. As we acknowledge these disparities, we will highlight reasons for these incongruences in care and clarify how clinicians can act to ensure that all patients are treated equitably, with equal levels of compassion.

Moving toward Mastery: Changes in Student Perceptions of Clerkship Assessment with Pass/Fail Grading and Enhanced Feedback

ProblemClerkship grades contribute to a summative assessment culture in clerkships and can therefore interfere with students' learning. For example, by focusing on summative, tiered clerkship grades, students often discount accompanying feedback that could inform future learning. This case report seeks to explore whether an assessment system intervention which eliminated tiered grades and enhanced feedback was associated with changes in student perceptions of clerkship assessment and perceptions of the clinical learning environment. Intervention: In January 2019, our institution eliminated tiered clerkship grading (honors/pass/fail) for medical students during the core clerkship year and implemented pass/fail clerkship grading along with required twice weekly, work-based assessments for formative feedback. Context: In this single institution, cross-sectional survey study, we collected data from fourth-year medical students one year after an assessment system intervention. The intervention entailed changing from honors/pass/fail to pass/fail grading in all eight core clerkships and implementing an electronic system to record twice-weekly real-time formative work-based assessments. The survey queried student perceptions on the fairness and accuracy of grading and the clinical learning environment-including whether clerkships were mastery- or performance-oriented. We compared responses from students one year after the assessment intervention to those from the class one year before the intervention. Comparisons were made using unpaired, two-tailed t-tests or chi-squared tests as appropriate with Cohen's d for effect size estimation for score differences. Content analysis was used to analyze responses from two open-ended questions about feedback and grading. Impact: Survey response rates were similar before and after intervention (76% (127/168) vs. 72% (118/163), respectively) with no between-group differences in demographics. The after-intervention group showed statistically significant increases in the following factors: "grades are transparent and fair" (Cohen's d = 0.80), "students receive useful feedback" (d = 0.51), and "resident evaluation procedures are fair" (d = 0.40). After-intervention respondents perceived the clerkship learning environment to be more mastery-oriented (d = 0.52), less performance approach-oriented (d = 0.63), and less performance avoid-oriented (d = 0.49). There were no statistical differences in the factors "attending evaluation procedures are fair," "evaluations are accurate," "evaluations are biased," or "perception of stereotype threat." Open-ended questions revealed student recommendations to improve clerkship summary narratives, burden of work-based assessment, and in-person feedback. Lessons Learned: After an assessment system change to pass/fail grading with work-based assessments, we observed moderate to large improvements in student perceptions of clerkship grading and the mastery orientation of the learning environment. Our intervention did not improve perceptions around bias in assessment in clerkships. Other medical schools may consider similar interventions to begin to address student concerns with clerkship assessment and promote a more adaptive learning environment.

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.

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.

What Bias Management Can Learn From Change Management? Utilizing Change Framework to Review and Explore Bias Strategies

This paper conducted a preliminary study of reviewing and exploring bias strategies using a framework of a different discipline: change management. The hypothesis here is: If the major problem of implicit bias strategies is that they do not translate into actual changes in behaviors, then it could be helpful to learn from studies that have contributed to successful change interventions such as reward management, social neuroscience, health behavioral change, and cognitive behavioral therapy. The result of this integrated approach is: (1) current bias strategies can be improved and new ones can be developed with insight from adjunct study fields in change management; (2) it could be more sustainable to invest in a holistic and proactive bias strategy approach that targets the social environment, eliminating the very condition under which biases arise; and (3) while implicit biases are automatic, future studies should invest more on strategies that empower people as "change agents" who can act proactively to regulate the very environment that gives rise to their biased thoughts and behaviors.

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.

Implicit racial bias among medical graduates and students by an IAT measure: a systematic review and meta-analysis

INTRODUCTION

Racial implicit bias is an unconscious response and behavior that affects interpersonal interactions and clinical decision-making.

AIMS

We attempted to meta-analyze the scores of implicit association test (IAT) to estimate pooled quantity of implicit racial bias among medical graduates and students METHODS: As far as we know, our study is the first systematic-based meta-analysis estimating the pooled score of implicit racial bias among physicians and medical students. Keywords were searched in Scopus, Web of Science, Google Scholar, PubMed, Science Direct, Cochrane, MEDLINE, Wiley online library, and ProQuest databases from 2011 since 2021. The IAT's pooled score estimates through a fixed-effect meta-analysis using STATA 15. Also, I² statistic was used to determine heterogeneity across the articles.

RESULTS

Out of 1177 articles, 29 studies entered to analysis. The pooled score of IAT among physicians and medical students was 0.28 (95% CI 0.13 to 0.43) and 0.35 (95% CI 0.03 to 0.67), respectively. The racial bias score of physician ranged from -0.12 to 0.62. While score of implicit association test for medical student ranged from -0.01 to 1.29.

CONCLUSION

Our meta-analysis revealed that there was an implicit anti-black attitude among physicians and medical students, but the size of this implicit racial bias was small. Although the level of racial bias in physicians and medical students was low, it could be reduced to the lowest level through informative programs and training in ways to control implicit attitudes.

Anti-Fat Biases of Occupational and Physical Therapy Assistants

Fat people are highly stigmatized, and anti-fat bias is pervasive resulting in stigma, prejudice, and discrimination, including in health care. The aim of this study was to explore occupational and physical therapy assistants' anti-fat biases. We analyzed secondary weight implicit association tests from 5,671 occupational/physical therapy assistants. The overwhelming majority (82%) of occupational/physical therapy assistants were implicitly prejudiced against fat people. Interventions for occupational/physical therapy assistants' anti-fat biases are critical, especially with increasing prevalence and responsibilities of occupational/physical therapy assistants in the provision of rehabilitation services.

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.

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.

Minimizing Unconscious Bias in Nursing School Admission

BACKGROUND

The potential exists for unconscious bias to influence decisions throughout the admission process to nursing school and derail holistic admission review processes. Although little is known about unconscious bias in nursing school admissions, unconscious bias has been demonstrated in nurse educators at levels similar to the general population.

METHOD

This article examines concepts of unconscious bias, factors that may interfere with accurate and fair assessment of applicants to nursing school, and ways to mitigate unconscious bias in the application and admission decision processes.

RESULTS

Interventions that have shown success in reducing unconscious bias center on increased awareness of the presence of unconscious bias and cognitive strategies that include motivation and effort to counter the unconscious bias.

CONCLUSION

Creating structures in the admission process that promote fairness and reduce the risk of relying on automatic judgments can minimize the influence of unconscious bias on admission decisions. [J Nurs Educ. 2021;60(6):317-323.].

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.

Racial Implicit Associations in Psychiatric Diagnosis, Treatment, and Compliance Expectations

OBJECTIVE

Racial and ethnic disparities are well documented in psychiatry, yet suboptimal understanding of underlying mechanisms of these disparities undermines diversity, inclusion, and education efforts. Prior research suggests that implicit associations can affect human behavior, which may ultimately influence healthcare disparities. This study investigated whether racial implicit associations exist among medical students and psychiatric physicians and whether race/ethnicity, training level, age, and gender predicted racial implicit associations.

METHODS

Participants completed online demographic questions and 3 race Implicit Association Tests (IATs) related to psychiatric diagnosis (psychosis vs. mood disorders), patient compliance (compliance vs. non-compliance), and psychiatric medications (antipsychotics vs. antidepressants). Linear and logistic regression models were used to identify demographic predictors of racial implicit associations.

RESULTS

The authors analyzed data from 294 medical students and psychiatric physicians. Participants were more likely to pair faces of Black individuals with words related to psychotic disorders (as opposed to mood disorders), non-compliance (as opposed to compliance), and antipsychotic medications (as opposed to antidepressant medications). Among participants, self-reported White race and higher level of training were the strongest predictors of associating faces of Black individuals with psychotic disorders, even after adjusting for participant's age.

CONCLUSIONS

Racial implicit associations were measurable among medical students and psychiatric physicians. Future research should examine (1) the relationship between implicit associations and clinician behavior and (2) the ability of interventions to reduce racial implicit associations in mental healthcare.

Implicit bias in stroke care: A recurring old problem in the rising incidence of young stroke

Stroke is a leading cause of morbidity and mortality worldwide. Although the majority of strokes affect the elderly, the incidence of stroke in young patients is on the rise. Prompt recognition of stroke symptoms and time critical therapies play a key role in management and prognosis of this condition. This is especially critical in young stroke patients, for whom delays in early recognition and treatment can result in many years of disability with associated social and financial burden. Misdiagnosis and unwarranted variation in treatment of stroke in young patients is problematic. Clinician implicit bias, the unconscious and unintentional process of judgement in healthcare decision-making, is a contributor to the short-falls in outcomes in this population. Interventions in this process have been shown to improve clinical outcomes in young stroke patients and represent an active area of study.

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.

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.