Fostering students' reflection about bias in healthcare: cognitive dissonance and the role of personal and normative standards

The Risk Perception of the Chinese Diaspora during the COVID-19 Pandemic: Targeting Cognitive Dissonance through Storytelling

The global COVID-19 pandemic in 2020 required risk communications to mitigate the virus' spread. However, social media not only conveyed health information to minimize the contagion, but also distracted from the threat by linking it to an externalized 'other'-primarily those appearing to be of Chinese descent. This disinformation caused the attribution of blame to Chinese people worldwide. In Canada's Greater Toronto Area, Chinese individuals reported widespread public stigma that compounded their risk of contagion; to the degree that it was driven by cognitive dissonance, it generated experiences of social and cultural vulnerability. In this paper, we draw on the aforementioned study's findings to explain how the risk perception and threat appraisal of Chinese diaspora individuals were impacted by different cognitive dissonance pathways. These findings explore how storytelling is a viable intervention with which to target and mitigate cognitive dissonance. Indeed, the mechanisms of cognitive dissonance can modify risk perception and mitigate social and cultural vulnerability, thereby averting potential long-term negative consequences for one's mental health and well-being. We hope our guidance, training educators to target pathways of cognitive dissonance by drawing on storytelling (with humour), can assist them to better convey information in ways that are more inclusive during public health emergencies.

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.

Transforming Professional Identity in Simulation Debriefing: A Systematic Metaethnographic Synthesis of the Simulation Literature

SUMMARY STATEMENT

There continues to be a lack of detailed understanding of how debriefing works and how it enables learning. To further our understanding and simultaneously illuminate current knowledge, a metaethnographic qualitative synthesis was undertaken to address the research question: how are interactions in simulation debriefing related to participant learning? Ten databases were searched (up to November 2020) and 17 articles were selected for inclusion.Initial interpretive synthesis generated 37 new concepts that were further synthesized to produce a new theoretical framework. At the heart of the framework is a concept of reflective work, where participants and faculty recontextualize the simulation experience bidirectionally with clinical reality: a process that facilitates sensemaking. This occurs in a learning milieu where activities such as storytelling, performance evaluation, perspective sharing, agenda setting, and video use are undertaken. The outcome is conceptualization of new future roles, clinical competence, and professional language development-a process of transforming professional identity.

An exploratory qualitative study of pharmacy student perspectives of implicit bias in pharmacy practice

INTRODUCTION

Implicit biases can contribute to unfair treatment in healthcare and exacerbate healthcare disparities. Little is known about the implicit biases that exist within pharmacy practice and their behavioral manifestations. The purpose of this study was to explore pharmacy student perspectives about implicit bias in pharmacy practice.

METHODS

Sixty-two second-year pharmacy students attended a lecture on implicit bias in healthcare and engaged in an assignment designed to explore their thoughts about how implicit bias manifests or may manifest within pharmacy practice. Students' qualitative responses were content analyzed.

RESULTS

Students reported several examples in which implicit bias may emerge in pharmacy practice. Various forms of potential bias were identified including bias associated with patients' race, ethnicity, and culture, insurance/financial status, weight, age, religion, physical appearance and language, lesbian, gay, bisexual, transgender, queer/questioning and gender identity, and prescriptions filled. Students identified several potential implications of implicit bias in pharmacy practice including unwelcoming non-verbal behavior on the part of providers, differences in time devoted to interacting with patients, differences in empathy and respect, inadequate counseling, and (un)willingness to provide services. Students also identified factors that could precipitate biased behaviors such as fatigue, stress, burnout, and multiple demands.

CONCLUSIONS

Pharmacy students believed that implicit biases manifested in many different ways and were potentially associated with behaviors that resulted in unequal treatment in pharmacy practice. Future studies should explore the effectiveness of implicit bias trainings on reducing the behavioral implications of bias in pharmacy practice.

"It's Always among Us. I Can't Act Like It's Not.": Women College Students' Perceptions of Physicians' Implicit Bias

Physicians have an opportunity to provide accurate and timely information about sexual behavior to individuals in their care. However, many young people, and in particular college women, are reticent to talk to their physicians about sexual behavior. One explanation for this reticence may be the fact that physicians' implicit bias has the potential to denigrate communication between physicians and patients. However, little is known about how patients perceive physicians' implicit bias, or to what extent it shapes a patient's beliefs about communicating with their physician. Qualitative analysis of in-depth, semi-structured interviews was used to describe and explain the way women college students perceive issues concerning physicians' implicit bias. Results were interpreted through the lens of Communication Privacy Management theory and revealed that participants either avoided or limited communication with a physician as a result of anticipating implicit bias. Major themes included "untangling identity and the effects of physicians' implicit bias" and "seeking to understand physicians' cognition and emotion." These findings have the potential to improve communication interventions both for women college students and healthcare professionals by introducing evidence of patients' perceptions of implicit biases along the intersection of race, young age, sexuality, and female gender in physician-patient communication about sexual behavior.

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.

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.

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.

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.

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 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.

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.

Postgraduate health promotion students' perceptions of at-risk populations: Those who smoke tobacco, are overweight or obese or drink alcohol at hazardous levels

Perceptions acquired during tertiary health promotion education can influence students’ interactions with their future service-users. Reflective practice can highlight these perceptions. Here we describe the findings of a reflective exercise conducted with postgraduate health promotion students as part of a learning activity. Students (n = 44) reflected on their understandings of at-risk populations in three priority areas—tobacco, obesity and alcohol. The activity aimed to deconstruct students’ understandings of these populations and identify understandings juxtaposed to the philosophical underpinnings of health promotion, for addressing through teaching and learning. Thematic analysis revealed students’ understanding of all three at-risk populations fit within five themes: apathy/lack of altruism, complexity/choice, pressure/control, escaping /excuses, and environmental contexts. Students also have varying levels of tolerance to at-risk populations, expressing greatest tolerance towards those whose addiction undermines choice and self-control, and least towards those who are overweight/obese or whose behaviour causes risk to others. Our findings show reflective practice is a valuable tool to help educators understand students’ attitudes and values and implement changes to support their future role in the community.

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.

Bridging the Expertise of Advocates and Academics to Identify Reproductive Justice Learning Outcomes

Phenomenon: Reproductive justice (RJ) is defined by women of color advocates as the right to have children, not have children and parent children while maintaining reproductive autonomy. In the United States, physicians have been complicit in multiple historical reproductive injustices, involving coercive sterilization of thousands of people of color, low income, and disabilities. Currently, reproductive injustices continue to occur; however, physicians have no formal RJ medical education to address injustices. The objective of this study was to engage leading advocates within the movement using a Delphi method to identify critical components for such a curriculum. Approach: In 2016, we invited 65 RJ advocates and leaders to participate in an expert panel to design RJ medical education. A 3-round Delphi survey was distributed electronically to identify content for inclusion in an RJ curriculum. In the next 2 survey rounds, experts offered feedback and revisions and rated agreement with including content recommendations in the final curriculum. We calculated descriptive statistics to analyze quantitative data. A team with educational expertise wrote learning outcomes based on expert content recommendations. Findings: Of the 65 RJ advocates and leaders invited, 41 participated on the expert panel of the Delphi survey. In the first survey, the expert panel recommended 58 RJ content areas through open-ended response. Over the next 2 rounds, there was consensus among the panel to include 52 of 58 of these areas in the curriculum. Recommended content fell into 11 broad domains: access, disparities, and structural competency; advocacy; approaches to reproductive healthcare; contemporary law and policy; cultural safety; historical injustices; lesbian, gay, bisexual, transgender, queer/questioning, and intersex health; oppression, power, and bias training; patient care; reproductive health; and RJ definitions. The 97 learning outcomes created from this process represented both unique and existing educational elements. Insights: A collaborative methodology infused with RJ values can bridge experts in advocacy and academics. New learning outcomes identified through this process can enhance medical education; however, it is just as important to consider education in RJ approaches to care as it is knowledge about that care. We must explore the pedagogic process of RJ medical education while considering that expertise in this area may exist outside of the medical community and thus there is a need to partner with RJ advocates. Finally, we expect to use innovative teaching methods to transform medical education and achieve an RJ focus.

Pre-clinical medical student reflections on implicit bias: Implications for learning and teaching

Context

Implicit bias affects health professionals’ clinical decision-making; nevertheless, published reports of medical education curricula exploring this concept have been limited. This research documents a recent approach to teaching implicit bias.

Methods

Medical students matriculating during 2014 and 2015 participated in a determinants of health course including instruction about implicit bias. Each submitted a reflective essay discussing implicit bias, the experience of taking the Implicit Association Test (IAT), and other course content. Using grounded theory methodology, student essays that discussed reactions to the IAT were analyzed for content themes based on specific statements mapping to each theme. Twenty-five percent of essays underwent a second review to calculate agreement between raters regarding identification of statements mapping to themes.

Outcome

Of 250 essays, three-quarters discussed students’ results on the IAT. Theme comments related to: a) experience taking the IAT, b) bias in medicine, and c) prescriptive comments. Most of the comments (84%) related to students’ acknowledging the importance of recognizing implicit bias. More than one-half (60%) noted that bias affects clinical decision-making, and one-fifth (19%) stated that they believe it is the physician’s responsibility to advocate for dismantling bias.

Conclusions

Through taking the IAT and developing an understanding of implicit bias, medical students can gain insight into the effect it may have on clinical decision-making. Having pre-clinical medical students explore implicit bias through the IAT can lay a foundation for discussing this very human tendency.

Selecting and Performing Service-Learning in a Team-Based Learning Format Fosters Dissonance, Reflective Capacity, Self-Examination, Bias Mitigation, and Compassionate Behavior in Prospective Medical Students

More compassionate behavior should make both patients and their providers happier and healthier. Consequently, work to increase this behavior ought to be a major component of premedical and medical education. Interactions between doctors and patients are often less than fully compassionate owing to implicit biases against patients. Such biases adversely affect treatment, adherence, and health outcomes. For these reasons, we studied whether selecting and performing service-learning projects by teams of prospective medical students prompts them to write reflections exhibiting dissonance, self-examination, bias mitigation, dissonance reconciliation, and compassionate behavior. Not only did these students report changes in their behavior to become more compassionate, but their reflective capacity also grew in association with selecting and performing team service-learning projects. Components of reflective capacity, such as reflection-on-action and self-appraisal, correlated strongly with cognitive empathy (a component of compassion) in these students. Our results are, however, difficult to generalize to other universities and other preprofessional and professional healthcare programs. Hence, we encourage others to test further our hypothesis that provocative experiences foster frequent self-examination and more compassionate behavior by preprofessional and professional healthcare students, especially when teams of students are free to make their own meaning of, and build trust and psychological safety in, shared experiences.

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.

Implicit Bias and the Feedback Paradox: Exploring How Health Professionals Engage With Feedback While Questioning Its Credibility

PURPOSE

Learners and practicing health professionals may dismiss emotionally charged feedback related to self, yet little research has examined how to address feedback that threatens an individual's identity. The implicit association test (IAT) provides feedback to individuals regarding their implicit biases. Anticipating feedback about implicit bias might be emotionally charged for mental health professionals, this study explored their experience of taking the IAT and receiving their results, to better understand the challenges of identity-threatening feedback.

METHOD

The researchers sampled 32 psychiatry nurses, psychiatrists, and psychiatric residents at Western University in Ontario, Canada, after they completed the mental illness IAT and received their results. Using constructivist grounded theory, semistructured interviews were conducted from April to October 2017 regarding participants' experience of taking the IAT. Using constant comparative analysis, transcripts were iteratively coded and analyzed for results.

RESULTS

While most participants critiqued the IAT and questioned its credibility, many also described the experience of receiving feedback about their implicit biases as positive or neutral. Most justified their implicit biases while acknowledging the need to better manage them.

CONCLUSIONS

These findings highlight a feedback paradox, calling into question assumptions regarding self-related feedback. Participants' reactions to the IAT suggest that potentially threatening self-related feedback may still be useful to participants who question its credibility. Further exploration of how the feedback conversation influences engagement with self-related feedback is needed.

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.

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.

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.

Qualitative Analysis of Student Pharmacists' Reflections of Harvard's Race Implicit Association Test

BACKGROUND AND PURPOSE

Identify and analyze pharmacy students' perceptions about their own implicit racial biases.

EDUCATIONAL ACTIVITY AND SETTING

First year pharmacy students (n = 97) enrolled in a Pharmacy Practice course completed a test, Harvard Race Implicit Association Test (IAT), for homework to uncover their unconscious black-white racial bias. All students then wrote at least one paragraph reflecting on if they agreed or disagreed with their results and why. At the beginning of class, students were given a brief survey to capture their IAT results and demographic information. Retrospectively and following Institutional Review Board approval, pharmacy students' reflections were subjected to thematic analysis with the assistance of NVivo 10 and descriptive analyses were completed of their demographic info.

FINDINGS

Out of the 97 students enrolled in this course, all completed the self-reflection. But only 90 completed the survey. From those that completed the survey, 54% (N = 49) self-identified as women. The average age was 22.6 years old. Most of the students (77%) identified themselves as White Non-Hispanic. Six percent (N = 5) identified as Black. Most students (66%) reported that their results from the Race IAT indicated some level of preference for European Americans; 13% of the students reported some level of preference for African-Americans. All students' reflections were categorized by their agreement or lack of agreement with their implicit association test results. Those that agreed with their results cited family, friends, and community contributing to their implicit biases. Students who did not agree with their results were subcategorized as denying their results, believing that their implicit association did not affect their behavior, or believing that the Race IAT was invalid.

DISCUSSION/SUMMARY

Many pharmacy students were found to be unaware of their implicit biases and some do not believe that these biases will negatively affect the treatment of others. Pharmacy curricula should be developed to provide adequate self-awareness training and space in the curriculum so students can challenge these unconscious beliefs.

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.

Medical Students' Implicit Bias and the Communication of Norms in Medical Education

ISSUE

Medical educators should consider how institutional norms influence medical students' perceptions of implicit bias. Understanding normative structures in medical education can shed light on why this influence is associated with students' resistance to implicit bias.

EVIDENCE

Extant research across diverse fields of study uncovers and theorizes layers of norms and normative systems and how they are related to ethical behavior. This review bridges the fields of communication, bioethics, and medical education, constructing an organized foundation and common language by which researchers can build effective educational interventions. First, the nature and effects of implicit bias are described. Second, the nature of normative systems in medical education is explicated. Concepts from the fields of education and communication are transferred to medical education. Third, the structure of the communication of norms in medical education is revealed, through theoretical research in bioethics and empirical medical education research.

IMPLICATIONS

Recommendations are provided for medical educators to improve activities intended to encourage reflection on implicit bias. These recommendations include reframing educational activities as endeavors in "personal" development and uncovering and transforming those normative structures that encourage resistance to implicit bias.

Mindfulness practice: A promising approach to reducing the effects of clinician implicit bias on patients

Like the population at large, health care providers hold implicit racial and ethnic biases that may contribute to health care disparities. Little progress has been made in identifying and implementing effective strategies to address these normal but potentially harmful unconscious cognitive processes. We propose that meditation training designed to increase healthcare providers' mindfulness skills is a promising and potentially sustainable way to address this problem. Emerging evidence suggests that mindfulness practice can reduce the provider contribution to healthcare disparities through several mechanisms including: reducing the likelihood that implicit biases will be activated in the mind, increasing providers' awareness of and ability to control responses to implicit biases once activated, increasing self-compassion and compassion toward patients, and reducing internal sources of cognitive load (e.g., stress, burnout, and compassion fatigue). Mindfulness training may also have advantages over current approaches to addressing implicit bias because it focuses on the development of skills through practice, promotes a nonjudgmental approach, can circumvent resistance some providers feel when directly confronted with evidence of racism, and constitutes a holistic approach to promoting providers' well-being. We close with suggestions for how a mindfulness approach can be practically implemented and identify potential challenges and research gaps to be addressed.

Instilling new habits: addressing implicit bias in healthcare professionals

There appears to be a fundamental inconsistency between research which shows that some minority groups consistently receive lower quality healthcare and the literature indicating that healthcare workers appear to hold equality as a core personal value. Recent evidence using Implicit Association Tests suggests that these disparities in outcome may in part be due to social biases that are primarily unconscious. In some individuals the activation of these biases may be also facilitated by the high levels of cognitive load associated with clinical practice. However, a range of measures, such as counter-stereotypical stimuli and targeted experience with minority groups, have been identified as possible solutions in other fields and may be adapted for use within healthcare settings. We suggest that social bias should not be seen exclusively as a problem of conscious attitudes which need to be addressed through increased awareness. Instead the delivery of bias free healthcare should become a habit, developed through a continuous process of practice, feedback and reflection.

The emotions of graduating medical students about prior patient care experiences

OBJECTIVES

To determine the emotional responses to patient care activities described by fourth year medical students.

METHODS

Qualitative content analysis for emerging themes in letters written by graduating medical students to patients during a Capstone Course. The patient need not be alive and the letter would never be sent.

RESULTS

Six themes emerged from student letters: (1) Sorrow for the depths of patient suffering; (2) Gratitude towards patients and their families; (3) Personal responsibility for care provided to patients; (4) Regret for poor care provided by the student or student's team; (5) Shattered expectations about medicine and training; and (6) Anger towards patients. Students expressed sensitivity to vulnerable patients, including those who were alone, unable to communicate, or for whom care was biased. Students' expressed powerlessness (inability to cure, managing a work-life balance, and challenges with hierarchy) in some essays.

CONCLUSION

At graduation, medical students describe strong emotions about previous patient care experiences, including difficulty witnessing suffering, disappointment with medicine, and gratitude to patients and their families

PRACTICE IMPLICATIONS

Providing regular opportunities for writing throughout medical education would allow students to recognize their emotions, reflect upon them and promote wellness that would benefit students and their patients.

Implicit bias and its relation to health disparities: a teaching program and survey of medical students

BACKGROUND

The varying treatment of different patients by the same physician are referred to as within provider disparities. These differences can contribute to health disparities and are thought to be the result of implicit bias due to unintentional, unconscious assumptions.

PURPOSES

The purpose is to describe an educational intervention addressing both health disparities and physician implicit bias and the results of a subsequent survey exploring medical students' attitudes and beliefs toward subconscious bias and health disparities.

METHODS

A single session within a larger required course was devoted to health disparities and the physician's potential to contribute to health disparities through implicit bias. Following the session the students were anonymously surveyed on their Implicit Association Test (IAT) results, their attitudes and experiences regarding the fairness of the health care system, and the potential impact of their own implicit bias. The students were categorized based on whether they disagreed ("deniers") or agreed ("accepters") with the statement "Unconscious bias might affect some of my clinical decisions or behaviors." Data analysis focused specifically on factors associated with this perspective.

RESULTS

The survey response rate was at least 69%. Of the responders, 22% were "deniers" and 77% were "accepters." Demographics between the two groups were not significantly different. Deniers were significantly more likely than accepters to report IAT results with implicit preferences toward self, to believe the IAT is invalid, and to believe that doctors and the health system provide equal care to all and were less likely to report having directly observed inequitable care.

CONCLUSIONS

The recognition of bias cannot be taught in a single session. Our experience supports the value of teaching medical students to recognize their own implicit biases and develop skills to overcome them in each patient encounter, and in making this instruction part of the compulsory, longitudinal undergraduate medical curriculum.

Using artistic-narrative to stimulate reflection on physician bias

BACKGROUND

Physician bias toward patients directly impacts patient care and health outcomes. However, too little research has been done investigating avenues to bring about self-awareness in this area to eliminate commonly held stereotypes that fuel physician bias.

PURPOSES

The purpose of this study was to explore the ways in which 2nd-year medical students' reflected on an artistic-narrative presentation given by a woman with sickle cell disease.

METHODS

A total of 320 2nd-year medical student essays were reviewed for content relevant to the artistic-narrative presentation. A total of 75 essays were identified and served as the data for this study. These 75 essays were analyzed using qualitative interpretive thematic content analysis to identify students' perceptions and reflections on culture in the healthcare environment and the patient-provider relationship.

RESULTS

The analysis of the reflective essays revealed that this exercise helped students acknowledge physician bias in pain treatment, foster empathetic views toward patients as individuals, and recognize various ways in which biased beliefs can provide incite in healthcare disparities.

CONCLUSIONS

These findings suggest that the combination of methods--art, narrative, and written reflection--helped students acknowledge their own bias as well as the ways in which taken-for-granted assumptions and biases can influence patient care.