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.

Inequitable care delivery toward COVID-19 positive people of color and people with disabilities.

This study aimed to explore provider observations of inequitable care delivery towards COVID-19 positive patients who are Black, Indigenous, and Other People of Color (BIPOC) and/or have disabilities and to identify ways the health workforce may be contributing to and compounding inequitable care. We conducted semi-structured interviews between April and November 2021 with frontline healthcare providers from Washington, Florida, Illinois, and New York. Using thematic analysis, major themes related to discriminatory treatment included decreased care, delayed care, and fewer options for care. Healthcare providers' bias and stigma, organizational bias, lack of resources, fear of transmission, and burnout were mentioned as drivers for discriminatory treatment. COVID-19 related health system policies such as visitor restrictions and telehealth follow-ups inadvertently resulted in discriminatory practices towards BIPOC patients and patients with disabilities. As patients experience lower quality healthcare during the pandemic, COVID-19-related restrictions and policies compounded existing inequitable care for these populations.

Imagining Improved Interactions: Patients' Designs To Address Implicit Bias.

Implicit biases may negatively influence healthcare providers' behaviors toward patients from historically marginalized communities, impacting providers' communication style, clinical decision-making, and delivery of quality care. Existing interventions to mitigate negative experiences of implicit biases are primarily designed to increase recognition and management of stereotypes and prejudices through provider-facing tools and resources. However, there is a gap in understanding and designing interventions from patient perspectives. We conducted seven participatory co-design workshops with 32 Black, Indigenous, People of Color (BIPOC), Lesbian, Gay, Bisexual, Transgender, Queer/Questioning (LGBTQ+), and Queer, Transgender, Black, Indigenous, People of Color (QTBIPOC) individuals to design patient-centered interventions that help them address and recover from provider implicit biases in primary care. Participants designed four types of solutions: accountability measures, real-time correction, patient enablement tools, and provider resources. These informatics interventions extend the research on implicit biases in healthcare through inclusion of valuable, firsthand patient perspectives and experiences.

Piloting web-based structural competency modules among internal medicine residents and graduate students in public health.

Introduction: Fewer than half of internal medicine program directors report any health disparities curriculum. We piloted a web-based healthcare disparities module among internal medicine (IM) residents to test effectiveness and feasibility, compared to a convenient sample of graduate students enrolled in a public health equity course. Methods: IM residents participated in an in-person session (module 1: introduction to racial and ethnic health disparities), but first, they completed a pre-module knowledge quiz. Two weeks later, they completed module 2: "unconscious associations" and a post-module knowledge quiz. For the control arm Yale School of Public Health (YSPH) students enrolled in a course on health disparities completed the pre-module knowledge quiz, module 1, and 2 as required by their course instructor. Results: Forty-nine IM residents and 22 YSPH students completed the pre-module quiz and Module 1. The mean (SD) score out of 25 possible points for the IM residents on the pre-module quiz was 16.1/25 (2.8), and 16.6/25 (3.2) for YSPH students, with no statistically significant difference. Nineteen residents (38.8%) completed the post-module quiz with a mean score of 16.7/25 (2.2), Hedge's g =0.23, compared to 18 (81.8%) YSPH students, whose mean (SD) score was 19.5/25 (2.1), Hedge's g=1.05. YSPH students' post-module quiz average was statistically significantly higher than their pre-module test score, as well as the residents' post-module test (P < 0.001). In examining participants' responses to specific questions, we found that 51% (n = 25) of residents wrongly defined discrimination with an emphasis on attitudes and intent as opposed to actions and impact, compared to 22.7% (n = 5) YSPH students before the module, vs. 63.2% (n = 12) and 88.9% (n = 16) respectively after. Conclusion: After completing a healthcare disparities course, graduate students in public health saw greater gains in knowledge compared to IM residents. Residents' responses showed knowledge gaps such as understanding discrimination, and highlight growth opportunity in terms of health equity education. Furthermore, embedding health equity education in required curricular activities may be a more effective approach.

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

OBJECTIVE: People who experience marginalization, including Black, Indigenous, People of Color (BIPOC) and Lesbian, Gay, Bisexual, Transgender, Queer, Plus (ie, all other marginalized genders and sexual orientations) people (LGBTQ+) experience discrimination during healthcare interactions, which negatively impacts patient-provider communication and care. Yet, scarce research examines the lived experience of unfair treatment among patients from marginalized groups to guide patient-centered tools that improve healthcare equity. MATERIALS AND METHODS: We interviewed 25 BIPOC and/or LGBTQ+ people about their experiences of unfair treatment and discrimination when visiting healthcare providers. Through thematic analysis, we describe participants' immediate reactions and longer-term consequences of those experiences. RESULTS: We identified 4 ways that participants reacted to discrimination in the moment: Fighting, Fleeing, Excusing, and Working Around Bias. Long-term consequences reflect 6 ways they coped: Delaying or Avoiding Care, Changing Healthcare Providers, Self-prescribing, Covering Behaviors, Experiencing Health Complications, and Mistrusting Healthcare Institutions. DISCUSSION: By describing how patients react to experiences of unfair treatment and discrimination, our findings enhance the understanding of health disparities as patients cope and struggle to speak out.To combat these problems, we identify 3 future directions for informatics interventions that improve provider behavior, support patient advocacy, and address power dynamics in healthcare. CONCLUSIONS: BIPOC and LGBTQ+ patients' perspectives on navigating unfair treatment and discrimination in healthcare offers critical insight into their experiences and long-term consequences of those experiences. Understanding the circumstances and consequences of unfair treatment, discrimination, and the impact of bias through this patient-centered lens is crucial to inform informatics technologies that promote health equity.

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

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

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

PROBLEM AND PURPOSE: Healthcare provider implicit bias influences the learning environment and patient care. Bias awareness is one of the key elements to be included in implicit bias education. Research on education enhancing bias awareness is limited. Bias awareness can motivate behavior change. The objective was to evaluate whether exposure to a brief online course, Implicit Bias in the Clinical and Learning Environment, increased bias awareness. MATERIALS AND METHODS: The course included the history of racism in medicine, social determinants of health, implicit bias in healthcare, and strategies to reduce the impact of implicit bias in clinical care and teaching. A sample of U.S. academic family, internal, and emergency medicine providers were recruited into the study from August to December 2019. Measures of provider implicit and explicit bias, personal and practice characteristics, and pre-post-bias awareness measures were collected. RESULTS: Of 111 participants, 78 (70%) were female, 81 (73%) were White, and 63 (57%) were MDs. Providers held moderate implicit pro-White bias on the Race IAT (Cohen's d = 0.68) and strong implicit stereotypes associating males rather than females with 'career' on the Gender-Career IAT (Cohen's d = 1.15). Overall, providers held no explicit race bias (Cohen's d = 0.05). Providers reported moderate explicit male-career (Cohen's d = 0.68) and strong female-family stereotype (Cohen's d = 0.83). A statistically significant increase in bias awareness was found after exposure to the course (p = 0.03). Provider implicit and explicit biases and personal and practice characteristics were not associated with an increase in bias awareness. CONCLUSIONS: Implicit bias education is effective to increase providers' bias awareness regardless of strength of their implicit and explicit biases and personal and practice characteristics. Increasing bias awareness is one step of many toward creating a positive learning environment and a system of more equitable healthcare.

Nurse bias and nursing care disparities related to patient characteristics: A scoping review of the quantitative and qualitative evidence.

INTRODUCTION: Investigations of healthcare workers' implicit attitudes about patient characteristics and differences in delivery of healthcare due to bias are increasingly common. However, there is a gap in our understanding of nurse-specific bias and care disparities. AIMS: To identify (a) the types of available evidence, (b) key factors and relationships identified in the evidence and (c) knowledge gaps related to nurse bias (nurse attitudes or beliefs towards a patient characteristic) and nursing care disparities (healthcare disparities related specifically to nursing care). METHODS: Authors completed a scoping review using the Joanne Briggs Institute method and PRISMA-SCR checklist. Five databases were searched. After screening, 215 research reports were included and examined. Data were extracted from research reports and assessed for thematic patterns and trends across multiple characteristics. RESULTS: Nurse bias and/or care disparity investigations have become increasingly common over the 38-year span of included reports. Multiple patient characteristics have been investigated, with the most common being race and/or ethnicity, gender and age. Twenty-nine of 215 studies identified a potential relationship between nurse bias regarding a characteristic and nursing care of individuals with that characteristic. Of these studies, 27 suggested the bias was associated with a negative disparate impact on nursing care. Only 12 reports included evaluating an intervention designed to reduce nurse bias or nursing care-related healthcare disparities. CONCLUSIONS: Despite increasing research focus on individual bias and disparities in healthcare, the accumulated knowledge regarding nurses has not significantly advanced past a descriptive, exploratory level. Nor has there been a consistent focus on the role of nurses, who represent the largest component of the professional healthcare workforce. RELEVANCE TO CLINICAL PRACTICE: National and international codes of ethics for nurses require provision of care according to individual, unique patient need, disregarding bias and incorporating patient characteristics into their plan of care.

COmmuNity-engaged SimULation Training for Blood Pressure Control (CONSULT-BP): A study protocol.

BACKGROUND: Healthcare professionals have negative implicit biases toward minority and poor patients. Few communication skills interventions target implicit bias as a factor contributing to disparities in health outcomes. We report the protocol from the COmmuNity-engaged SimULation Training for Blood Pressure Control (CONSULT-BP), a trial evaluating a novel educational and training intervention targeting graduate medical and nursing trainees that is designed to mitigate the effects of implicit bias in clinical encounters. The CONSULT-BP intervention combines knowledge acquisition, bias awareness, and practice of bias mitigating skills in simulation-based communication encounters with racially/ethnically diverse standardized patients. The trial evaluates the effect of this 3-part program on patient BP outcomes, self-reported patient medication adherence, patient-reported quality of provider communication, and trainee bias awareness. METHODS: We are conducting a cluster randomized trial of the intervention among cohorts of internal medicine (IM), family medicine (FM), and nurse practitioner (NP) trainees at a single academic medical center. We are enrolling entire specialty cohorts of IM, FM, and NP trainees over a 3-year period, with each academic year constituting an intervention cycle. There are 3 cycles of implementation corresponding to 3 sequential academic years. Within each academic year, we randomize training times to 1 of 5 start dates using a stepped wedge design. The stepped wedge design compares outcomes within training clusters before and after the intervention, as well as across exposed and unexposed clusters. Primary outcome of blood pressure control is measured at the patient-level for patients clustered within trainees. Eligible patients for outcomes analysis are: English-speaking; non-White racial/ethnic minority; Medicaid recipient (regardless of race/ethnicity); hypertension; not have pregnancy, dementia, schizophrenia, bipolar illness, or other serious comorbidities that would interfere with hypertension self-control; not enrolled in hospice. Secondary outcomes include trainee bias awareness. A unique feature of this trial is the engagement of academic and community stakeholders to design, pilot test and implement a training program addressing healthcare. DISCUSSION: Equipping clinicians with skills to mitigate implicit bias in clinical encounters is crucial to addressing persistent disparities in healthcare outcomes. Our novel, integrated approach may improve patient outcomes. TRIAL REGISTRATION: NCT03375918. PROTOCOL VERSION: 1.0 (November 10, 2020).

Underrepresentation of Racial Minorities in Breast Surgery Literature: A Call for Increased Diversity and Inclusion.

OBJECTIVE: In this study, the extent of racial diversity in images of breast-related plastic surgery published literature was investigated to better understand disparities that exist in breast surgery. BACKGROUND: The lack of racial diversity in images of skin color in surgery literature can perpetuate implicit bias and stereotypes. Implicit bias can affect the way patients are evaluated, diagnosed, and treated. The visual aspects of plastic surgery make a lack of diversity in imagery especially impactful on patient care and outcomes. METHODS: Published medical images and graphics depicting human skin were analyzed across 4 major plastic surgery journals. Up to 4 years were chosen a priori to evaluate from each journal and represented the initial year of color image publication, the year of study initiation (2016), and representative years for a given decade (2000 and 2010). Images and graphics were tabulated, rated by Fitzpatrick scale and categorized into "White" or "non-White." Data were evaluated with pair-wise and linear regression statistics. RESULTS: Of the 2774 images and 353 graphics that met inclusion criteria, only 184 (8.18%) images and 9 graphics (6.34%) depicted non-White skin. Temporal analysis showed that there is an increased diversity of images published since 2010 with 0% of images being non-White before and 7.3% to 10.3% after 2010. International and multi-national authors tended to publish more non-White images. CONCLUSIONS: There is insufficient racial diversity visually represented in the breast-related plastic surgery literature with a small degree of progress made towards more equitable imagery over time. Increasing awareness of image content, and the need for equitable visual representation may allow for improved racial diversity in surgical literature.

Broken down by bias: Healthcare biases experienced by BIPOC and LGBTQ+ patients.

Bias toward historically marginalized patients affects patient-provider interactions and can lead to lower quality of care and poor health outcomes for patients who are Black, Indigenous, People of Color (BIPOC) and Lesbian, Gay, Bisexual, Transgender and Gender Diverse (LGBTQ+). We gathered experiences with biased healthcare interactions and suggested solutions from 25 BIPOC and LGBTQ+ people. Through qualitative thematic analysis of interviews, we identified ten themes. Eight themes reflect the experience of bias: Transactional Care, Power Inequity, Communication Casualties, Bias-Embedded Medicine, System-level problems, Bigotry in Disguise, Fight or Flight, and The Aftermath. The remaining two themes reflect strategies for improving those experiences: Solutions and Good Experiences. Characterizing these themes and their interconnections is crucial to design effective informatics solutions that can address biases operating in clinical interactions with BIPOC and LGBTQ+ patients, improve the quality of patient-provider interactions, and ultimately promote health equity.

Role of implicit bias in pediatric cancer clinical trials and enrollment recommendations among pediatric oncology providers.

BACKGROUND: Provider implicit bias can negatively affect clinician-patient communication. In the current study, the authors measured implicit bias training among pediatric oncology providers and exposure to implicit association tests (IATs). They then assessed associations between IATs for race and socioeconomic status (SES) and recommendations for clinical trial enrollment. METHODS: A prospective multisite study was performed to measure implicit bias among oncology providers at St. Jude Children's Research Hospital and affiliate clinics. An IAT was used to assess bias in the domains of race and SES. Case vignettes were used to determine an association between bias and provider recommendation for trial enrollment. Data were analyzed using Student t tests or Wilcoxon tests for comparisons and Jonckheere-Terpstra tests were used for association. RESULTS: Of the 105 total participants, 95 (90%) had not taken an IAT and 97 (92%) had no prior implicit bias training. A large effect was found for (bias toward) high SES (Cohen d, 1.93) and European American race (Cohen d, 0.96). The majority of participants (90%) had a vignette score of 3 or 4, indicating recommendation for trial enrollment for most or all vignettes. IAT and vignette scores did not significantly differ between providers at St. Jude Children's Research Hospital or affiliate clinics. No association was found between IAT and vignette scores for race (P = .58) or SES (P = .82). CONCLUSIONS: The authors noted a paucity of prior exposure to implicit bias self-assessments and training. Although these providers demonstrated preferences for high SES and European American race, this did not appear to affect recommendations for clinical trial enrollment as assessed by vignettes.

Health Promotion Programs and Policies in the Workplace: An Exploratory Study With Alaska Businesses.

INTRODUCTION: We examined health insurance benefits, workplace policies, and health promotion programs in small to midsize businesses in Alaska whose workforces were at least 20% Alaska Native. Participating businesses were enrolled in a randomized trial to improve health promotion efforts. METHODS: Twenty-six Alaska businesses completed from January 2009 through October 2010 a 30-item survey on health benefits, policies, and programs in the workplace. We generated frequency statistics to describe overall insurance coverage, and to detail insurance coverage, company policies, and workplace programs in 3 domains: tobacco use, physical activity and nutrition, and disease screening and management. RESULTS: Businesses varied in the number of employees (mean, 250; median, 121; range, 41-1,200). Most businesses offered at least partial health insurance for full-time employees and their dependents. Businesses completely banned tobacco in the workplace, and insurance coverage for tobacco cessation was limited. Eighteen had onsite food vendors, yet fewer than 6 businesses offered healthy food options, and even fewer offered them at competitive prices. Cancer screening and treatment were the health benefits most commonly covered by insurance. CONCLUSION: Although insurance coverage and workplace policies for chronic disease screening and management were widely available, significant opportunities remain for Alaska businesses to collaborate with federal, state, and community organizations on health promotion efforts to reduce the risk of chronic illness among their employees.

Barriers and bridges to implementing a workplace wellness project in Alaska.

CONTEXT: The vast, rugged geography and dispersed population of Alaska pose challenges for managing chronic disease risk. Creative, population-based approaches are essential to address the region's health needs. The American Cancer Society developed Workplace Solutions, a series of evidence-based interventions, to improve health promotion and reduce chronic disease risk in workplace settings. ISSUES: To adapt Workplace Solutions for implementation in eligible Alaskan businesses, research teams with the University of Washington and the Alaska Native Tribal Health Consortium collaborated to address various geographic, intervention, and workplace barriers. Terrain, weather, and hunting seasons were frequent geographic challenges faced over the entire course of the pilot study. Coordinating several research review boards at the university, workplace, and regional tribal health organizations; study staff turnover during the entire course of the study; and difficulties obtaining cost-effective intervention options were common intervention barriers. Few workplaces meeting initial study eligibility criteria, turnover of business contacts, and a downturn in the state economy were all significant workplace barriers. LESSONS LEARNED: Flexibility, organization, responsiveness, communication, and collaboration between research staff and businesses were routinely required to problem-solve these geographic, intervention, and workplace barriers.

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.

Patient Representation in Medical Literature: Are We Appropriately Depicting Diversity?

BACKGROUND: Racial disparities exist in the accessibility, delivery, and quality of healthcare. Clinical images are central to plastic surgery, but choice of images in the literature is susceptible to implicit biases. The objective of this study was to determine if published images reflect the racial demographic of patients. METHODS: A search for color photographs and rendered graphics depicting human skin was completed in 6 plastic surgery journals and the New England Journal of Medicine Images in Clinical Medicine for each decade between 1992 and 2017. For each article, images were categorized as white or nonwhite based on Fitzpatrick Scale (1-3 versus 4-6). Additionally, the authors' geographic region was documented. Proportional data and average number of nonwhite images per article were compared. Regression analyses were performed to assess the correlation of time and geographic region on nonwhite images. RESULTS: In total, 24,209 color photographs and 1,671 color graphics were analyzed. In plastic surgery journals, 22% of photographs were nonwhite and the average number of photographs per article with white skin was 5.4 compared with 1.6 with nonwhite skin (P < 0.0001). There was a significant increase in nonwhite photographs over time (r = 0.086, P < 0.001) and association of nonwhite photographs with international authors (r = 0.12, P < 0.001). CONCLUSIONS: Roughly 60%-70% of the world population and 30% of US cosmetic patients are nonwhite. Images in plastic surgery literature reflect neither racial demographics by global region nor the patient population seeking surgery. To advance equitable care, images should better represent the racial composition of the populations served.

Equitable Imagery in the Preclinical Medical School Curriculum: Findings From One Medical School.

PURPOSE: The unequal representation of women and people of color compared with men and whites in medical school textbooks has been well documented, as have health care inequities, and biases-both overt and implicit-by health care providers and in access to care. The authors investigated whether this bias exists in PowerPoint slides used in didactic material for preclinical students at one medical school. METHOD: The authors analyzed 747 "decks" of slides from 33 preclinical courses in the medical school curriculum at the University of Washington School of Medicine in the years spanning 2009 to 2011. The authors coded the human images into various sex- and race-specific classifications and evaluated the distribution of images into these categories. RESULTS: Of the 4,033 images that could be coded by sex, 39.6% (1,595) were female and 60.5% (2,438) were male. Of the 5,230 images that could be coded by race/ethnicity, 78.4% (4,100) were white and 21.6% (1,130) were persons of color. Thus, images of whites and males predominated. CONCLUSIONS: The proportion of images used in didactic courses at one school of medicine is not representative of the U.S. population in terms of race or sex. The authors discuss the potential sources and impact of this bias, make a case for sex and race diversity in didactic imagery, and propose possible avenues for further research and curricular reform in an era when the population is becoming increasingly racially and ethnically diverse.