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] ß = -1.29 [0.41]), all subdomains of communication (mean [SD] ß = -1.17 [0.52] to -1.43 [0.59]), and overall global ratings (mean [SD] ß = -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.

After the Discontinuation of Step 2 CS: A Collaborative Statement from the Directors of Clinical Skills Education (DOCS).

Issue: The United States Medical Licensing Exam (USMLE) Step 2 Clinical Skills Examination (Step 2 CS), the only clinical skills competency testing required for licensure in the United States, has been discontinued. Evidence: This exam, though controversial, propelled a movement emphasizing the value of clinical skills instruction and assessment in undergraduate medical education. While disappointed by the loss of this national driver that facilitated standardization of clinical skills education, the Directors of Clinical Skills Education (DOCS) see prospects for educational innovation and growth. DOCS is a national organization and inclusive community of clinical skills education leaders. This statement from DOCS regarding the discontinuation of USMLE Step 2 CS has been informed by DOCS meetings, listserv discussions, an internal survey, and a review of recent literature. Implications: Rigorous clinical skills assessment remains central to effective and patient-centered healthcare. DOCS shares specific concerns as well as potential solutions. Now free from the external pressure to prepare students for success on Step 2 CS, clinical skills educators can reprioritize content and restructure clinical skills programs to best meet the needs of learners and the ever-evolving healthcare landscape. DOCS, as an organization of clinical skills leaders, makes the following recommendations: 1) Collaboration amongst institutions must be prioritized; clinical skills assessment consortia should be expanded. 2) Governing, accrediting, and licensing organizations should leverage their influence to support and require high quality clinical skills assessments. 3) UME clinical skills leaders should develop ways to identify students who perform with exceptional, borderline, and poor clinical skills at their local institutions. 4) UME leadership should fully commit resources and curricular time to graduate students with excellent clinical skills.

A resource efficient and reliable standard setting method for OSCEs: Borderline regression method using standardized patients as sole raters in clinical case encounters with medical students.

Finding a reliable, practical and low-cost criterion-referenced standard setting method for performance-based assessments has proved challenging. The borderline regression method of standard setting for OSCEs has been shown to estimate reliable scores in studies using faculty as raters. Standardized patients (SPs) have been shown to be reliable OSCE raters but have not been evaluated as raters using this standard setting method. Our study sought to find whether SPs could be reliably used as sole raters in an OSCE of clinical encounters using the borderline regression standard setting method.SPs were trained for on a five-point global rating scale. In an OSCE for medical students, SPs completed skills checklists and the global rating scale. The borderline regression method was used to create case passing scores. We estimated the dependability of the final pass or fail decisions and the absolute dependability coefficients for global ratings, checklist scores, and case pass-score decisions using generalizability theory.The overall dependability estimate is 0.92 for pass or fail decisions for the complete OSCE. Dependability coefficients (0.70-0.86) of individual case passing scores range demonstrated high dependability.Based on our findings, the borderline regression method of standard setting can be used with SPs as sole raters in a medical student OSCE to produce a dependable passing score. For those already using SPs as raters, this can provide a practical criterion-referenced standard setting method for no additional cost or faculty time.

Novel use of an OSCE to assess medical students' responses to a request for a low value diagnostic imaging test: A mixed methods analysis.

OBJECTIVE: Evaluate medical students' communication skills with a standardized patient (SP) requesting a low value test and describe challenges students identify in addressing the request. METHODS: In this mixed-methods study, third-year students from two medical schools obtained a history, performed a physical examination, and counseled an SP presenting with uncomplicated low back pain who requests an MRI which is not indicated. SP raters evaluated student communication skills using a 14-item checklist. Post-encounter, students reported whether they ordered an MRI and challenges faced. RESULTS: Students who discussed practice guidelines and risks of unnecessary testing with the SP were less likely to order an MRI. Students cited several challenges in responding to the SP request including patient characteristics and circumstances, lack of knowledge about MRI indications and alternatives, and lack of communication skills to address the patient request. CONCLUSIONS: Most students did not order an MRI for uncomplicated LBP, but only a small number of students educated the patient about the evidence to avoid unnecessary imaging or the harm of unnecessary testing. PRACTICE IMPLICATIONS: Knowledge about unnecessary imaging in uncomplicated LBP may be insufficient to adhere to best practices and longitudinal training in challenging conversations is needed.

Comparing scientific worldviews between allopathic medical degree and East Asian medicine degree students utilizing the thinking about science survey instrument (TSSI).

BACKGROUND: Integrative medicine has become a new healthcare model due to the growing evidence base for complementary and integrative therapies. However, some question whether complementary and integrative therapies can truly be integrated with biomedicine due to differences in underlying paradigms and theoretical bases. This study aimed to explore differences in scientific worldviews between students studying East Asian medicine and those completing an allopathic medical degree using the validated Thinking about Science Survey Instrument (TSSI). METHODS: 122 medical students from Albert Einstein College of Medicine (Einstein) and 48 East Asian medicine students from the Pacific College of Health and Science (Pacific College) participated in this study. Participants completed the TSSI, a 60-item Likert-scale instrument that quantitatively measures the sociocultural resistance to, and support for science. Item and category means were compared between each group using an independent sample t-test. RESULTS: Distinct differences were seen between the two groups of students with regard to age, gender distribution and prior education. Einstein students were generally supportive of science and Pacific College students were generally supportive of/positively neutral to science. Einstein students more strongly affirmed the relationship of science in relation to the categories of Epistemology, Public Health, Emotion and Aesthetics, the Economy, and Public Policy. Pacific College students more strongly affirmed the relationship between science and the category Race and Gender. There were no differences in the categories of Environment and Resource, Science for All, and Religion and Morality. CONCLUSION: This study suggests that there are differences underlying the scientific worldviews of Einstein and Pacific College students, particularly with regard to Epistemology and Public Health. Such differences may be related to the different theoretical knowledge bases and ways of viewing health within the two disciplines. Despite demographic and educational differences between the two groups their overall scientific worldviews were similar with neither group expressing disparate views. This suggests that both groups may be receptive to the value of other paradigms. Providing courses that focus on different therapeutic approaches and paradigms during medical training may foster interprofessional understanding and collaborative practice between health professionals of different medical disciplines.

Step Up-Not On-The Step 2 Clinical Skills Exam: Directors of Clinical Skills Courses (DOCS) Oppose Ending Step 2 CS.

Recently, a student-initiated movement to end the United States Medical Licensing Examination Step 2 Clinical Skills and the Comprehensive Osteopathic Medical Licensing Examination Level 2-Performance Evaluation has gained momentum. These are the only national licensing examinations designed to assess clinical skills competence in the stepwise process through which physicians gain licensure and certification. Therefore, the movement to end these examinations and the ensuing debate merit careful consideration. The authors, elected representatives of the Directors of Clinical Skills Courses, an organization comprising clinical skills educators in the United States and beyond, believe abolishing the national clinical skills examinations would have a major negative impact on the clinical skills training of medical students, and that forfeiting a national clinical skills competency standard has the potential to diminish the quality of care provided to patients. In this Perspective, the authors offer important additional background information, outline key concerns regarding the consequences of ending these national clinical skills examinations, and provide recommendations for moving forward: reducing the costs for students, exploring alternatives, increasing the value and transparency of the current examinations, recognizing and enhancing the strengths of the current examinations, and engaging in a national dialogue about the issue.

Longitudinal Faculty Development Program to Promote Effective Observation and Feedback Skills in Direct Clinical Observation.

Introduction: We developed a longitudinal faculty development program to maximize faculty training in direct clinical observation (DCO) and feedback, as there was a perceived need for higher quality of DCO and feedback. To achieve this, we created a behaviorally anchored DCO instrument and worked to improve faculty skills in this area. Methods: We describe an innovative model of faculty training that is learner centered and reinforces evidence-based principles of effective feedback that are introduced and then repeated in all sessions. The training centers on both peer-led observation of and feedback on faculty learners' recorded DCO feedback encounters, and is guided by our DCO instrument. Residents and faculty completed surveys to assess program impact. Qualitative responses were analyzed for themes. The Wilcoxon signed rank test was used to examine significance of difference in feedback quality before and after DCO faculty development education sessions. Results: Our faculty development program has been well received and had a significant impact on quality of faculty feedback, as rated by resident learners. Discussion: Our faculty development model is effective at growing faculty learners' DCO and feedback skills. Potential strengths of this program include the use of a behaviorally anchored DCO instrument, longitudinal and experiential faculty development, and use of small-group peer review of recorded faculty feedback encounters. We have found that when their learning needs are attended to, faculty learners cultivate a deep appreciation for principles of effective feedback. In fact, faculty feedback skills can be enhanced in the eyes of resident learners.

Who's misbehaving? Perceptions of unprofessional social media use by medical students and faculty.

BACKGROUND: Social media use by physicians offers potential benefits but may also be associated with professionalism problems. The objectives of this study were: 1) to examine and compare characteristics of social media use by medical students and faculty; 2) to explore the scope of self- and peer-posting of unprofessional online content; and 3) to determine what actions were taken when unprofessional content was viewed. METHODS: An anonymous, web-based survey was sent to medical students and faculty in October, 2013 at the Albert Einstein College of Medicine in Bronx, New York. RESULTS: Three-quarters of medical students reported using social media "very frequently" (several times a day), whereas less than one-third of faculty did so (p < .001). Medical students reported using privacy settings more often than faculty (96.5 % v. 78.1 %, p < .001). Most medical students (94.2 %) and faculty (94.1 %) reported "never" or "occasionally" monitoring their online presence (p = 0.94). Medical students reported self-posting of profanity, depiction of intoxication, and sexually suggestive material more often than faculty (p < .001). Medical students and faculty both reported peer-posting of unprofessional content significantly more often than self-posting. There was no association between year of medical school and posting of unprofessional content. CONCLUSION: Medical students reported spending more time using social media and posting unprofessional content more often than did faculty.

Depression and stress amongst undergraduate medical students.

BACKGROUND: The demands placed on medical trainees pose a challenge to personal wellbeing, leading to burnout and erosion of empathy. However, it is unclear at what point in medical education this decline begins. Although many schools have begun to design and implement wellness programs for their students, the medical education community's experience in evaluating their impact is limited. METHODS: The authors designed a wellness needs assessment of all medical students at the Albert Einstein College of Medicine in order to assess students' health behaviors, stress and depressive symptoms. The online survey was administered to all medical students from the classes of 2014 and 2015 at the beginning of their first year of medical school and again at the end of their third year. Chi-square and T-tests were run comparing the survey responses of the two classes. RESULTS: There was a significant increase in perceived stress from an average of 5.51 in the first year to 6.49 in the third year (p = .0001). The number of students at risk for depression, defined as a CES-D score greater than 16, was 94 (28.4%) in the first year and 131 (39.0%) in their third year (p = .004). CONCLUSIONS: This study demonstrates a significant increase in the proportion of students at risk for depression in their third year as compared to the first year as well as an increase in perceived stress. In response to these findings, the authors took a multi-disciplinary approach in the development of a comprehensive program to address student wellness, including efforts to address issues specific to the clinical clerkships. This program is unique in that its design, inception and ongoing evaluation have taken the needs of an entire medical school class into account.

Spiritual versus religious identity: a necessary distinction in understanding clinicians' behavior and attitudes toward clinical practice and medical student teaching in this realm.

Social sciences view spirituality and religion separately; medicine views them together. We identified distinctions regarding clinical practice and teaching among clinician educators based on their self-identified spirituality versus religiosity. We emailed a 24-item survey on spiritual/religious (S/R) issues to clinician educators (n = 1067) at our institution. Three summary scales were created. Responses to statements, 'I consider myself to be spiritual' and 'I consider myself to be religious' generated four comparison groups: 'spiritual only,' 'religious only,' 'both spiritual and religious' and 'neither.' Analyses employed ANOVA and T tests. A total of 633 (59%) surveys were completed. Four percentage self-identified as 'religious only'; remaining respondents divided evenly, about 30% into each of the other categories. Groups differed from one another on all summary scales (p < .0001). Using T tests, the 'spiritual only' group differed from the 'religious only' group regarding teaching. The 'spiritual and religious' group had the highest mean ratings for all summary scales. The 'neither' and 'religious only' group had the lowest mean ratings. Clinicians' spiritual versus religious identity is associated with differences in behavior/attitudes regarding S/R toward clinical practice and medical student teaching. These findings elucidate opportunities for faculty development to explore effects of beliefs on behavior and attitudes within this realm.

Assessing third-year medical students' ability to address a patient's spiritual distress using an OSCE case.

PURPOSE: To inform curricular development by assessing the ability of third-year medical students to address a patient's spiritual distress during an acute medical crisis in the context of an objective structured clinical examination (OSCE) case. METHOD: During March and April 2010, 170 third-year medical students completed an eight-station videotaped OSCE at Albert Einstein College of Medicine of Yeshiva University. One of the standardized patients (SPs) was a 65-year-old man with acute chest pain who mentioned his religious affiliation and fear of dying. If prompted, he revealed his desire to speak with a chaplain. The SP assessed students' history taking, physical examination, and communication skills. In a postencounter written exercise, students reported their responses to the patient's distress via four open-ended questions. Analysis of the postencounter notes was conducted by three coders for emergent themes. Clinical skills performance was compared between students who reported making chaplain referral and those who did not. RESULTS: A total of 108 students (64%) reported making a chaplain referral; 4 (2%) directly addressed the patient's religious/spiritual beliefs. Students' clinical performance scores showed no significant association with whether they made a chaplain referral. CONCLUSIONS: Findings suggest that the majority of medical students without robust training in addressing patients' spiritual needs can make a chaplain referral when faced with a patient in spiritual crisis. Yet, few students explicitly engaged the patient in a discussion of his beliefs. Thus, future studies are needed to develop more precise assessment measures that can inform development in spirituality and medicine curricula.

Interprofessional student education: exchange program between Albert Einstein College of Medicine and Pacific College of Oriental Medicine.

The growing popularity of complementary and alternative medicine (CAM), of which estimated 38% of adults in the United States used in 2007, has engendered changes in medical school curricula to increase students' awareness of it. Exchange programs between conventional medical schools and CAM institutions are recognized as an effective method of interprofessional education. The exchange program between Albert Einstein College of Medicine (Einstein, Yeshiva University) and Pacific College of Oriental Medicine, New York campus (PCOM-NY) is in its fifth year and is part of a broader relationship between the schools encompassing research, clinical training, interinstitutional faculty and board appointments, and several educational activities. The Einstein/PCOM-NY student education exchange program is part of the Einstein Introduction to Clinical Medicine Program and involves students from Einstein learning about Chinese medicine through a lecture, the experience of having acupuncture, and a four-hour preceptorship at the PCOM outpatient clinic. The students from PCOM learn about allopathic medicine training through an orientation lecture, a two-and-a-half-hour dissection laboratory session along side Einstein student hosts, and a tour of the clinical skills center at the Einstein campus. In the 2011/2012 offering of the exchange program, the participating Einstein and PCOM students were surveyed to assess the educational outcomes. The data indicate that the exchange program was highly valued by all students and provided a unique learning experience. Survey responses from the Einstein students indicated the need for greater emphasis on referral information, which has been highlighted in the literature as an important medical curriculum integrative medicine competency.

"How am I doing?" Teaching medical students to elicit feedback during their clerkships.

AIM: This study seeks to explore formative feedback during clerkships from the student perspective and to determine whether a modest intervention aimed at students can impact their attitudes or behavior regarding feedback interactions. BACKGROUND: Multiple studies document medical student dissatisfaction with a lack of feedback from attending physicians and housestaff regarding their performance during their clerkship rotations. While feedback is essential to skill building, and feedback-seeking a necessary component of self-awareness, studies indicate that little progress has been made in understanding or addressing these student concerns. METHODS: Participants included the entire third-year class of a medical school (n = 189). They were surveyed about their attitudes and experience with regard to receiving feedback during clerkships using both Likert-type questions and open-ended questions. Half of the class was assigned to receive a brief intervention, a workshop dealing with the nature of feedback and ways to actively elicit it from housestaff and attendings. RESULTS: Qualitative results indicated that students initially conceived of feedback as a linear process, from instructor to student, and they felt both the lack of time on the ward and instructors' apparent inapproachability were major barriers in receiving feedback. The group of students who attended the feedback workshop reported a positive change in their attitude toward obtaining feedback and a significant increase in their feedback-seeking behavior. CONCLUSIONS: Students can learn to assume a more active role in their learning interactions with instructors during their clerkships.

Teaching medical students how to use interpreters: a three year experience.

Disparities in health exist among ethnic/racial groups, especially among members with limited English proficiency (LEP). The session described in this paper aimed to teach medical students the skills needed to communicate with patients with LEP. Description - We created a required session titled "Cross-Cultural Communication-Using an Interpreter" for third-year medical students with learning objectives and teaching strategies. The session plans evolved over three years. Program Evaluation - Students' perceived efficacy using retrospective pre/post test analysis (n = 110, 86% response rate) administered 7 weeks post-session revealed that 77.3% of students felt "more prepared to communicate with a patient with LEP", 77.3% to "give proper instructions to an untrained interpreter" and 76.4% to "access a hospital language line". Conclusion - Our curricular intervention was effective in increasing students' perceived efficacy in communicating with a patient with LEP, using untrained interpreters and accessing a hospital language line. Skills practice and discussion of using interpreters should be a part of medical education.

Use of complementary and alternative medicine in inner-city persons with or at risk for HIV infection.

Previous studies have shown that use of complementary and alternative medicine (CAM) is prevalent among HIV-infected persons, but have focused primarily on men who have sex with men. To determine factors associated with CAM use in an inner city population, individuals (n = 93) recruited from two established cohort studies were interviewed between October and November 2004. The interview assessed the use of dietary supplements and other CAM therapies, reasons for CAM use, and use of prescription medications. Study participants were 52% male and 47% HIV infected. Median age was 50 years, and 60% reported illicit drug use ever. CAM use during the prior 6 months was reported by 94%, with 48% reporting daily use of a dietary supplement. Vitamin C, vitamin E, and soy were used more often by HIV-infected than uninfected persons (p < 0.05). Prevention of illness was the most common reason for dietary supplement use (27%). HIV-infected persons were more likely than uninfected persons (95% versus 67%) to report use of both dietary supplements and prescription medications within the past 6 months (p < 0.001). In multivariate analysis, HIV infection (odds ratio [OR] 3.1, CI 1.3, 7.7) was the only factor associated with daily dietary supplement use whereas gender, race/ethnicity, working in the last year, homelessness, and financial comfort were not associated. CAM use among persons with or at risk for HIV infection due to drug use or high-risk heterosexual behaviors is common, and is used almost exclusively as an adjunct and not an alternative to conventional health care.

An intervention to improve advance emergency contraceptive prescribing practices among academic primary care physicians.

BACKGROUND: Primary care physicians care for reproductive-aged women, yet do not routinely counsel women about or prescribe contraceptives, including emergency contraception (EC). STUDY DESIGN: We used a pre-/post-study to design to assess whether the proportion of primary care physicians who counseled women about and prescribed EC increased 6 months after a peer-led intervention with educational and reminder components. Participants included 36 residents and attending physicians at an academically affiliated internal medicine practice from July 2004 to June 2005 (when prescription was required for EC in New York). Data were collected by self-administered questionnaire. RESULTS: At baseline, 37% of participants had counseled women about EC and 34% had prescribed EC in the prior month. After the intervention, 80% of participants had counseled women about EC (p<.001) and 66% had prescribed EC (p=.03) in the prior month. CONCLUSION: Six months after a peer-led intervention including educational and reminder components, the proportion of primary care physicians who had counseled women about and prescribed EC in the past month increased significantly.

Teaching clinical skills through videotape review: a randomized trial of group versus individual reviews.

BACKGROUND: Video review is a valuable educational tool for teaching communication skills. Many studies have demonstrated its efficacy with individual learners, but few studies have addressed its use in a group format. PURPOSE: To assess the educational benefits of group versus individual video review of standardized patient encounters through the evaluations of 4th-year students at the Albert Einstein College of Medicine. METHODS: Students (128) who participated in a 7-station, standardized patient, clinical competency exam were randomly assigned to an individual or small group video review of selected segments of these encounters in 2000-2001. Students filled out an anonymous 13-item questionnaire assessing the experience and provided open-ended responses. RESULTS: With both review formats, most students had a positive learning experience (80%), found it less stressful than they expected (67%), and would not have preferred to do the review the other way (84%). Students randomized to individual reviews had a significantly higher level of satisfaction with the amount of time for the session (91% vs. 78%, p < .05) and the amount of feedback they received (95% vs. 79%, p = .01) and were more likely to view the session as a positive learning experience (88% vs. 73%, p < .05). Students in the individual review format were more likely to choose self-assessed weak segments (63% vs. 49%, p = .01). Students' comments indicated that they appreciated the value of peer review in a group setting. CONCLUSIONS: Although both group reviews and individual reviews of videotaped standardized patient encounters were received well by the students, there were several statistical differences in favor of the individual format.

A model for educational feedback based on clinical communication skills strategies: beyond the "feedback sandwich".

BACKGROUND: Feedback is an essential tool in medical education, and the process is often difficult for both faculty and learner. There are strong analogies between the provision of educational feedback and doctor-patient communication during the clinical encounter. DESCRIPTION: Relationship-building skills used in the clinical setting-Partnership, Empathy, Apology, Respect, Legitimation, Support (PEARLS)-can establish trust with the learner to better manage difficult feedback situations involving personal issues, unprofessional behavior, or a defensive learner. Using the stage of readiness to change (transtheoretical) model, the educator can "diagnose" the learner's stage of readiness and employ focused interventions to encourage desired changes. EVALUATION: This approach has been positively received by medical educators in faculty development workshops. CONCLUSIONS: A model for provision of educational feedback based on communication skills used in the clinical encounter can be useful in the medical education setting. More robust evaluation of the construct validity is required in actual training program situations.