Towards equitable learning environments for medical education: Bias and the intersection of social identities.

CONTEXT: Medical educators are increasingly paying attention to how bias creates inequities that affect learners across the medical education continuum. Such bias arises from learners' social identities. However, studies examining bias and social identities in medical education tend to focus on one identity at a time, even though multiple identities often interact to shape individuals' experiences. METHODS: This article examines prior studies on bias and social identity in medical education, focusing on three social identities that commonly elicit bias: race, gender and profession. By applying the lens of intersectionality, we aimed to generate new insights into intergroup relations and identify strategies that may be employed to mitigate bias and inequities across all social identities. RESULTS: Although different social identities can be more or less salient at different stages of medical training, they intersect and impact learners' experiences. Bias towards racial and gender identities affect learners' ability to reach different stages of medical education and influence the specialties they train in. Bias also makes it difficult for learners to develop their professional identities as they are not perceived as legitimate members of their professional groups, which influences interprofessional relations. To mitigate bias across all identities, three main sets of strategies can be adopted. These strategies include equipping individuals with skills to reflect upon their own and others' social identities; fostering in-group cohesion in ways that recognise intersecting social identities and challenges stereotypes through mentorship; and addressing intergroup boundaries through promotion of allyship, team reflexivity and conflict management. CONCLUSIONS: Examining how different social identities intersect and lead to bias and inequities in medical education provides insights into ways to address these problems. This article proposes a vision for how existing strategies to mitigate bias towards different social identities may be combined to embrace intersectionality and develop equitable learning environments for all.

From ideal to real: a qualitative study of the implementation of in situ interprofessional simulation-based education.

BACKGROUND: Despite the widespread adoption of interprofessional simulation-based education (IPSE) in healthcare as a means to optimize interprofessional teamwork, data suggest that IPSE may not achieve these intended goals due to a gap between the ideals and the realities of implementation. METHODS: We conducted a qualitative case study that used the framework method to understand what and how core principles from guidelines for interprofessional education (IPE) and simulation-based education (SBE) were implemented in existing in situ IPSE programs. We observed simulation sessions and interviewed facilitators and directors at seven programs. RESULTS: We found considerable variability in how IPSE programs apply and implement core principles derived from IPE and SBE guidelines with some principles applied by most programs (e.g., "active learning", "psychological safety", "feedback during debriefing") and others rarely applied (e.g., "interprofessional competency-based assessment", "repeated and distributed practice"). Through interviews we identified that buy-in, resources, lack of outcome measures, and power discrepancies influenced the extent to which principles were applied. CONCLUSIONS: To achieve IPSE's intended goals of optimizing interprofessional teamwork, programs should transition from designing for the ideal of IPSE to realities of IPSE implementation.

Exploring the role of power during debriefing of interprofessional simulations.

Interprofessional simulation aims to improve teamwork and patient care by bringing participants from multiple professions together to practice simulated patient care scenarios. Yet, power dynamics may influence interprofessional learning during simulation, which typically occurs during the debriefing. This issue has received limited attention to date but may explain why communication breakdowns and conflicts among healthcare teams persist despite widespread adoption of interprofessional simulation. This study explores the role of power during interprofessional simulation debriefings. We collected data through observations of seven interprofessional simulation sessions and debriefings, four focus groups with simulation participants, and four interviews with simulation facilitators. We identified ways in which power dynamics influenced discussions during debriefing and sometimes limited participants' willingness to share feedback and speak up. We also found that issues related to power that arose during interprofessional simulations often went unacknowledged during the debriefing, leaving healthcare professionals unprepared to navigate power discrepancies with other members of healthcare teams in practice. Given that the goal of interprofessional simulation is to allow professionals to learn together about each other, explicitly addressing power in debriefing after interprofessional simulation may enhance learning.

The impact of interprofessional perspective-taking on moral distress in the pediatric intensive care unit.

Moral distress arises when constraints outside of healthcare professionals' control prohibit them from acting according to the ethically sound course of action. It can be triggered by poor communication and different perspectives between professionals. We examined whether and how taking the perspective of the other profession reduces moral distress among pediatric intensive care nurses and physicians. Using elements of a previously published scale, we created a Vignette-based Moral Distress Rating Scale (V-MDRS). Study participants from three sites included 105 nurses and 34 physicians who read a patient vignette with their own profession's perspective, completed the V-MDRS, then received the other profession's perspective and completed the V-MDRS again. We conducted semi-structured interviews with nine nurses and nine physicians who completed the V-MDRS to explore how interprofessional perspective-taking impacts moral distress. Nurses experienced higher baseline moral distress than physicians (mean ± standard deviation 31.1 ± 6.9 vs 26.4 ± 5, P < .001), and at two study sites nurses' moral distress declined after reading the physician's perspective. Findings from interviews suggest that physicians were already sensitized to nurses' perspective and that perspective-taking may be particularly beneficial to cohesive teams with strong relationships. Thus, encouraging interprofessional perspective-taking may mitigate moral distress in healthcare professionals.

A Scoping Review of Interprofessional Simulation-Based Team Training Programs.

SUMMARY STATEMENT: Interprofessional simulation-based team training (ISBTT) is promoted as a strategy to improve collaboration in healthcare, and the literature documents benefits on teamwork and patient safety. Teamwork training in healthcare is traditionally grounded in crisis resource management (CRM), but it is less clear whether ISBTT programs explicitly take the interprofessional context into account, with complex team dynamics related to hierarchy and power. This scoping review examined key aspects of published ISBTT programs including (1) underlying theoretical frameworks, (2) design features that support interprofessional learning, and (3) reported behavioral outcomes. Of 4854 titles identified, 58 articles met inclusion criteria. Most programs were based on CRM and related frameworks and measured CRM outcomes. Only 12 articles framed ISBTT as interprofessional education and none measured all interprofessional competencies. The ISBTT programs may be augmented by integrating theoretical concepts related to power and intergroup relations in their design to empower participants to navigate complex interprofessional dynamics.

Using Simulation to Teach Learners in Health Care Behavioral Skills Related to Diversity, Equity, and Inclusion: A Scoping Review.

SUMMARY STATEMENT: Bias is commonplace in the health care environment and can negatively impact patients and their health outcomes. Simulation has long been shown to be an effective teaching tool for communication skills in health care, but it has rarely been used to deliver concrete behavioral skills that address issues of diversity, equity, and inclusion (DEI). This scoping review examines 23 published articles surrounding the use of simulation in health care education to impart behavioral skills that reduce bias and promote DEI. Included articles described various behavioral skills including communication, history-taking, and system/community-level advocacy. The most commonly used simulation modality to teach these skills included the use of simulated participants (16 articles, 70%). The main DEI topics addressed in the trainings included sexual orientation/gender identity, language, and culture/ethnicity. Based on findings from this review, the authors suggest recommendations for educators who are considering teaching DEI-related skills through simulation.

Standardized Patients' Perspectives on Bias in Student Encounters.

PURPOSE: Standardized patient (SP) encounters are widely used in health professional education to evaluate trainees' clinical skills. Prior literature suggests that bias can influence the evaluations of student learners in SP-student encounters. Understanding how SPs perceive bias in their work and how they view their role in mitigating or perpetuating bias in simulation is an important first step in addressing bias in the SP-student encounter. METHOD: Researchers designed a qualitative interview study and conducted 16 semistructured interviews with SPs at the University of California, San Francisco Kanbar Simulation Center from July through September of 2020. Participants were selected using purposive sampling. The interviews were transcribed and analyzed by researchers using inductive thematic analysis. Researchers met iteratively to reconcile codes and identify themes. RESULTS: SPs identified bias occurring in multiple directions: SP-to-student, student-to-SP, student-to-character, and SP-to-character. SPs were hesitant to label their own biases and instead used words such as "comfort" or "preference." SPs reported little bias from students, because students were being evaluated and therefore behaving carefully. Additionally, SPs perceived bias in the implementation of health care simulation, which manifests as underrepresentation of certain groups amongst actors and character descriptions. Most SPs felt that they should play a role in mitigating bias in SP-student encounters, including addressing bias that occurs, challenging stereotypes, teaching about cultural differences, and/or being conscious of bias in their assessments of learners. CONCLUSIONS: In the SP-student encounter, bias can occur on many levels and between many individuals, including between the SP and the character they are portraying. Identifying the areas in which bias can exist can help simulation educators mitigate bias.

A Vicious Cycle of Bias: Residents' Perceptions of Leadership in Health Care.

PURPOSE: Despite growing interest in shared leadership models, autocratic physician leadership remains the norm in health care. Stereotype and bias limit leadership by members of other professions. Furthermore, traditional views of effective clinical leadership emphasize agentic behaviors associated with male gender. To shift the prototypical concept of a leader from a male physician to a more inclusive prototype, a better understanding of prototype formation is needed. This study examines leader prototypes and their development among resident physicians through the lens of leadership categorization theory. METHOD: One researcher conducted semistructured interviews with anesthesia and internal medicine residents at a single institution, asking participants to describe their ideal team leader and comment on the video-recorded performance of either a male or female nurse practitioner (NP) leading a simulated resuscitation. Interview questions explored participants' perceptions of NPs as team leaders and how these perceptions developed. The researchers conducted deductive analysis to examine leadership prototypes and prototype formation, and inductive analysis to derive additional themes. RESULTS: The majority of residents described a male physician as the ideal resuscitation team leader. Exposure to male physician leaders, and lack of exposure to NP leaders, contributed to this prototype formation. Residents described a vicious cycle in which bias against female and NP leaders diminished acceptance of their leadership by team members, resulting in decreased confidence and performance, further aggravating bias. CONCLUSIONS: These results provide suggestions for interventions that can help shift the leadership prototype in health care and promote shared leadership models. These include increasing exposure to different professionals of either gender in leadership roles and increased representation in educational materials, education about effective leadership strategies to create awareness of the benefits of shared leadership, and reflection during team training to increase awareness of bias and the backlash effect faced by individuals whose behaviors counter established stereotypes.

Effect of Professional Background and Gender on Residents' Perceptions of Leadership.

PURPOSE: To examine the impact of professional background and gender of a resuscitation team leader on residents' perceptions of leadership skills. METHOD: The authors video-recorded a scripted, simulated resuscitation scenario twice, with either a male or a female team leader. They copied each video and labeled the leader as physician (MD) or nurse practitioner (NP), creating 4 conditions: female NP, female MD, male NP, or male MD. The authors recruited resident participants from 5 specialties at 4 institutions; they randomly assigned residents to view one version of the video and rate the team leader's performance using the Ottawa Crisis Resource Management Global Rating Scale (Ottawa CRM) in an online survey. The authors conducted 2-way ANOVA to examine interactions between team leader gender and profession on Ottawa CRM ratings. RESULTS: One hundred sixty residents responded (89 females, 71 males). A statistically significant main effect of team leader gender on residents' ratings was found in 2 of the 6 Ottawa CRM domains, leadership (F1,156 = 6.97, P = .009) and communication skills (F1,156 = 8.53, P = .004), due to lower ratings for female than male leaders (5.29 ± 0.95 vs 5.74 ± 1.17; 5.05 ± 1.20 vs 5.57 ± 1.06). There was no effect of profession on ratings and no significant interaction between profession and gender of the team leader on ratings for any of the domains. CONCLUSIONS: These findings indicate bias among residents against females as team leaders. Mitigating such bias is essential to successfully establish shared leadership models in health care.

The Effect of Limited English Proficiency on Pediatric Hospital Readmissions.

BACKGROUND: The relationship between limited English proficiency (LEP) and worse pediatric health outcomes is well documented. OBJECTIVES: To determine the relationship between LEP status and pediatric hospital readmissions. METHODS: We performed a retrospective cohort analysis of children ≤ 18 years old admitted to a tertiary children's hospital from 2008 to 2014. The main exposure was LEP status. Independent variables included sex, age, race/ethnicity, insurance, median household income, surgical/medical status, severity of illness (SOI), the presence of a complex chronic condition, and length of stay. Primary outcome measures were 7- and 30-day readmission. RESULTS: From 67 473 encounters, 7- and 30-day readmission rates were 3.9% and 8.2%, respectively. LEP patients were more likely to be younger, poorer, and Hispanic; have lower SOI; and government-subsidized insurance. Adjusted odds for 7- or 30-day readmission for LEP versus English-proficient (EP) patients were 1.00 (P = .99) and 0.97 (P = .60), respectively. Hispanic ethnicity (adjusted odds ratio [aOR]: 1.26 [P = .002] and 1.14 [P = .02]), greater SOI (aOR: 1.04 [P < .001] and 1.05 [P < .001]), and the presence of a complex chronic condition (aOR: 2.31 [P < .001] and 3.03 [P < .001]) were associated with increased odds of 7- and 30-day readmission, respectively. White LEP patients had increased odds of 7- and 30-day readmission compared with white EP patients (aOR: 1.46 [P = .006] and 1.32 [P = .007]) and the poorest LEP patients had increased odds of 7- and 30-day readmission compared with the poorest EP patients (aOR: 1.77 [P = .04] and 2.00 [P < .001]). CONCLUSIONS: This is the first large study evaluating the relationship between LEP and pediatric hospital readmission. There was no increased risk of readmission in LEP patients compared with EP patients.

Multiple intracellular routes in the cross-presentation of a soluble protein by murine dendritic cells.

Soluble heat shock fusion proteins (Hsfp) stimulate mice to produce CD8+ CTL, indicating that these proteins are cross-presented by dendritic cells (DC) to naive CD8 T cells. We report that cross-presentation of these proteins depends upon their binding to DC receptors, likely belonging to the scavenger receptor superfamily. Hsfp entered DC by receptor-mediated endocytosis that was either inhibitable by cytochalasin D or not inhibitable, depending upon aggregation state and time. Most endocytosed Hsfp was transported to lysosomes, but not the small cross-presented fraction that exited early from the endocytic pathway and required access to proteasomes and TAP. Naive CD8 T cell (2C and OT-I) responses to DC incubated with Hsfp at 1 microM were matched by incubating DC with cognate octapeptides at 1-10 pM, indicating that display of very few class I MHC-peptide complexes per DC can be sufficient for cross-presentation. With an Hsfp (heat shock protein-OVA) having peptide sequences for both CD4+ (OT-II) and CD8+ (OT-I) cells, the CD4 cells responded far more vigorously than the CD8 cells and many more class II MHC-peptide than class I MHC-peptide complexes were displayed.