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

Defensive Responses to Implicit Association Tests and Bias Awareness in an Implicit Bias Mitigation Training

Background

Implicit bias education that utilizes the Implicit Association Test (IAT) to raise self-awareness of bias can induce defensiveness.

Objective

To describe clinical learners' bias awareness, self-perceptions of bias relative to colleagues (better-than-average), implicit and explicit biases and defensive response to the IATs.

Design

Cross-sectional study.

Participants

Internal medicine and family medicine residents, and Doctor of Nursing Practice students at a public medical and nursing school affiliated with a disproportionate share hospital and who completed an implicit bias recognition and mitigation educational program (including didactics, IATs, and communication skills training and practice with standardized patients) in 2018-2019.

Main Measures

We measured implicit and explicit attitudes and stereotypes, reactions to IAT results (defensive or not defensive), better-than-average perceptions, bias awareness and participants' characteristics. We examined associations between defensive responses to the IAT and participant characteristics, self-reported explicit biases, bias awareness within self, society, and healthcare, and IAT scores.

Key Results

Of N=61 respondents, 57% were female and 59% White. We found moderate implicit bias favoring White people versus Black people, weak bias favoring White people versus Hispanic/Latinx people and moderate bias favoring White people on both race and ethnicity medical compliance stereotype IATs. Participants demonstrated awareness of bias in society and healthcare, but not within self. Eighteen percent were defensive regarding their IAT results. Perceptions of own bias (self) were always of their having less bias than their colleagues, and they were better-than-average. There were no statistically significant associations between IAT scores and participant demographics and no interaction effect between implicit bias, defensiveness and better-than-average scores.

Conclusion

Clinical learners hold moderate implicit biases, believe they have less bias than others, and almost 1-in-5 have a defensive response to IAT feedback. It is important to design implicit bias educational interventions to include reflection on personal bias and provide a safe environment to minimize defensiveness.

Seeing Ourselves in Others: Understanding and Addressing Biases in Medical School Admissions Processes

Purpose

Medical school admissions is a vital area for advancing diversity, equity, and inclusion (DEI). Integrating bias recognition and management (BRM) within the context of admissions is critical in advancing DEI. However, there is a dearth of empirically informed literature on BRM in the admissions context. Therefore, this study sought to explore how individuals involved in admissions decisions process and integrate bias related feedback.

Methods

The authors conducted a qualitative exploratory study using constructivist grounded theory. 21 semi-structured interviews were conducted with various participants in the admissions process at a North American medical school who had participated in bias related training. Participants included medical school faculty, senior medical students, and community volunteers.

Results

Overall, participants expressed diverse perspectives on their personal biases and how these biases impact admissions decisions. Their reflections were shaped by their identities, values, and priorities, which varied based on whether they were faculty members, students, or community members. Participants also highlighted that their biases influenced their perceptions of the ideal admissions candidate, thus influencing their decision-making process. They emphasized the need for more opportunities to engage in dialogue with peers to openly share and discuss how to recognize and manage their biases.

Conclusion

Our study suggests that fostering critical reflection about identity tensions, building and sustaining a community of practice, and facilitating sustained dialogue may provide admissions committees with an evidence-informed, meaningful, and sustained approach to advancing DEI through bias recognition and management.

Communicating neurological prognosis in the prenatal period: a narrative review and practice guidelines

Clinicians may face an array of challenges in conducting fetal neurological consultations including prognostic uncertainty, a lack of training in fetal counseling, and limited opportunity to build rapport with families. In this setting, it is critical to employ high-quality, family-centered care to allow expectant parents to make informed decisions. Despite the challenges and gravity of these consultations, there remains limited data outlining best conduct and communication practices. This narrative review aims to summarize relevant literature around counseling within fetal neurology, focusing on three key themes: (1) discussing neurological prognosis and uncertainty, (2) navigating evolving decision making, (3) recognizing bias and understanding patient context. We provide practical recommendations to clinicians conducting fetal neurological counseling and outline future research priorities. IMPACT: Fetal neurological conditions can have a significant impact on child short- and long-term health outcomes. Prenatal consultations are an important venue to discuss information regarding fetal prognosis and decision making with expectant parents. However, there is limited evidence supporting best communication practices within this setting. This review summarizes current literature around expectant parent prognostic communication preferences and outlines practical recommendations and priorities for future research.

Pedagogies of discomfort and disruption: A meta-narrative review of emotions and equity-related pedagogy

INTRODUCTION

Discussions about equity in professional education can evoke a range of complex emotions. Approaches to emotionally challenging pedagogies may vary across professions. Comparative explorations of these approaches may yield fresh insights that could enhance our teaching and learning strategies within health professions education. Therefore, the authors sought to explore how the professional contexts of medicine, nursing and teacher education approach the role of emotions in equity-related pedagogy.

METHODS

A meta-narrative approach was utilised to synthesise existing research on the relationship between emotions and equity-related pedagogy in three different professions. Six databases were searched using key terms yielding 3102 titles. After screening, 58 articles were selected for extraction. Through coding and analysis, the authors sought to gain a deeper understanding of why emotions are relevant to equity-related pedagogy in each profession, and how each profession grapples with emotional dissonance.

RESULTS

There were both contrasting and complimentary meta-narratives about emotions and equity-related learning in medicine, nursing and teacher education. All three professions viewed emotions as relevant and essential for equity-related learning. Medicine and nursing sought to make emotions accessible and explicit, while foregrounding the need for learners to build skills to understand and address emotions such as critical reflection and dialogue. Meta-narratives in teacher education were similar to medicine and nursing; however, teacher education further emphasised the role of emotions in fostering community, trust and empathy.

DISCUSSION

Existing meta-narratives regarding emotions and equity-related pedagogy in health professions suggest that medicine and nursing have acknowledged the intrinsic role that emotions play in equity-related learning yet lag behind teacher education in considering the role of emotions as a socio-cultural connector and mediator.

Residents' perceptions of what makes feedback valuable in workplace-based learning: A discrete choice experiment

INTRODUCTION

Research on feedback has shifted emphasis away from its 'delivery' to consideration of the interaction between individual learners and their 'feedback provider'. The complexity inherent in determining whether feedback is perceived as valuable by learners, however, can quickly overwhelm educators if every interaction must be considered completely idiosyncratic. We, therefore, require a better understanding of variability in the ways in which feedback is perceived. To that end, we ran a discrete choice experiment aimed at determining residents' preferences and whether discernible patterns exist across learners regarding factors that influence perceptions of feedback's learning value.

METHODS

We performed a discrete choice experiment in which respondents were asked to read a clinical case and select repetitively between two feedback scenarios that differed according to six attributes identified from the literature as influencing feedback credibility: Dialogue, Focus, Relationship, Situation, Source and Valence. By systematically varying the levels of each attribute contained in the scenarios and asking residents to choose which from each pair they deemed more valuable for learning, a mixed logit model and latent class analysis could be applied to determine learners' feedback preferences and whether clusters of preference exist.

RESULTS

Ninety-five elderly care medicine residents in the Netherlands completed the questionnaire. Their responses indicated that Valence, Dialogue, Relationship and Focus each accounted for about 20% of their preferences regarding the type of feedback perceived to offer the most learning value. Source and Situation were less influential, each accounting for 11% of the choices made. A latent class model with three clusters of respondents best accounted for the heterogeneity in feedback preferences. A total of 62% of respondents could be assigned to one of the three profiles with at least 80% probability. None of the respondents' characteristics (seniority, residency programme nor sex) were related to the feedback preference profile.

DISCUSSION

Our findings suggest that 'how' feedback is provided has a greater influence on perceived learning value than who provides it. That said, variability exists in resident perceptions with no evidence (as yet) of factors that predict individual preferences. As such, tailoring to the needs and reactions of individual learners is likely to require open and ongoing conversations, and we recommend using the learner profiles generated through this study as a starting point because they provide classifications that could facilitate effective connections for the majority of residents.

More specific feedback: why "confidence" in feedback is too ambiguous

High quality feedback should be delivered in a timely manner, based on specific direct observation, and formulated to be actionable on the part of the trainee. Utilizing "confidence" as a point of feedback does not meet these criteria given the ambiguity and lack of actionable steps towards improvement. "Confidence"-based feedback makes a judgment about the trainee's internal state leading to potentially gender or culturally biased feedback. There is a risk of emotional harm for trainees when it is integrated into feedback and it is unclear if there is a role for the use of "confidence" in medical education. We are calling for a moratorium on the utilization of the word "confidence" in feedback in medical education until further studies are performed to assess its potential place. At this time, educators should refrain from "confidence"-based feedback and shift the focus towards more specific, actionable, behavioral-based feedback.

The effectiveness of psychiatric genetic counseling training: An analysis of 13 international workshops

Studies have consistently shown that psychiatric genetic counseling (pGC) helps people with psychiatric conditions by increasing empowerment and self-efficacy, and addressing emotions like guilt. Yet, it is not routinely provided. Genetic counselors and trainees express low confidence in their ability to provide meaningful pGC, especially in the absence of adequate training. Therefore, to address this gap a "Psychiatric Genetic Counseling for Genetic Counselors" (PG4GC) workshop was developed and delivered to 13 groups of participants (primarily qualified genetic counselors and trainees) between 2015 and 2023 (10 workshops were delivered in-person, and three virtually). Participants completed quantitative questionnaires both before and after completing the workshop to assess their comfort, knowledge, behavior, and feeling of being equipped to provide pGC. In total, 232 individuals completed the pre-workshop questionnaire and 154 completed the post-workshop questionnaire. Participants felt more comfortable, knowledgeable, and equipped to provide pGC, and reported being more likely to address psychiatric concerns after the workshop, regardless of whether they were trainees or practicing professionals and whether they completed the workshop in-person or virtually. This study suggests that the PG4GC workshop is an effective educational tool in pGC training that may aid in broader implementation of the service.

Mobile technologies to support workplace-based assessment for entrustment decisions: Guidelines for programs and educators: AMEE Guide No. 154

With the rise of competency-based medical education and workplace-based assessment (WBA) since the turn of the century, much has been written about methods of assessment. Direct observation and other sources of information have become standard in many clinical programs. Entrustable professional activities (EPAs) have also become a central focus of assessment in the clinical workplace. Paper and pencil (one of the earliest mobile technologies!) to document observations have become almost obsolete with the advent of digital technology. Typically, clinical supervisors are asked to document assessment ratings using forms on computers. However, accessing these forms can be cumbersome and is not easily integrated into existing clinical workflows. With a call for more frequent documentation, this practice is hardly sustainable, and mobile technology is quickly becoming indispensable. Documentation of learner performance at the point of care merges WBA with patient care and WBA increasingly uses smartphone applications for this purpose.This AMEE Guide was developed to support institutions and programs who wish to use mobile technology to implement EPA-based assessment and, more generally, any type of workplace-based assessment. It covers backgrounds of WBA, EPAs and entrustment decision-making, provides guidance for choosing or developing mobile technology, discusses challenges and describes best practices.

Unconscious Bias among Health Professionals: A Scoping Review

BACKGROUND

Unconscious biases are one of the causes of health disparities. Health professionals have prejudices against patients due to their race, gender, or other factors without their conscious knowledge. This review aimed to provide an overview of research on unconscious bias among health professionals and to investigate the biases that exist in different regions of the world, the health professions that are considered, and the research gaps that still exist.

METHODS

We conducted a scoping review by systematically searching PubMed/MEDLINE, CINAHL, PsycINFO, PsycARTICLES, and AMED. All records were double-screened and included if they were published between 2011 and 2021.

RESULTS

A total of 5186 records were found. After removing duplicates (n = 300), screening titles and abstracts (n = 4210), and full-text screening (n = 695), 87 articles from 81 studies remained. Studies originated from North America (n = 60), Europe (n = 13), and the rest of the world (n = 6), and two studies were of global scope. Racial bias was investigated most frequently (n = 46), followed by gender bias (n = 11), weight bias (n = 10), socio-economic status bias (n = 9), and mental illness bias (n = 7). Most of the studies were conducted by physicians (n = 51) and nurses (n = 20). Other health care professionals were rarely included in these studies.

CONCLUSIONS

Most studies show that health professionals have an implicit bias. Racial biases among physicians and nurses in the USA are well confirmed. Research is missing on other biases from other regions and other health professions.

It Takes a Village: Optimal Graduate Medical Education Requires a Deliberately Developmental Organization

Coaching is proposed as a means of improving the learning culture of medicine. By fostering trusting teacher-learner relationships, learners are encouraged to embrace feedback and make the most of failure. This paper posits that a cultural shift is necessary to fully harness the potential of coaching in graduate medical education. We introduce the deliberately developmental organization framework, a conceptual model focusing on three core dimensions: developmental communities, developmental aspirations, and developmental practices. These dimensions broaden the scope of coaching interactions. Implementing this organizational change within graduate medical education might be challenging, yet we argue that embracing deliberately developmental principles can embed coaching into everyday interactions and foster a culture in which discussing failure to maximize learning becomes acceptable. By applying the dimensions of developmental communities, aspirations, and practices, we present a six-principle roadmap towards transforming graduate medical education training programs into deliberately developmental organizations.

The State of the Science of Nurses' Implicit Bias: A Call to Go Beyond the Face of the Other and Revisit the Ethics of Belonging and Power

This article summarizes the current state of nurses' implicit bias and discusses the phenomenon from Levinas' face of the Other and ethics of belonging, Watson's human caring and unitary caring science, and Chinn's peace and power theory. Nurses' implicit bias is a global issue; the primary sources of nurses' implicit bias include race/ethnicity, sexuality, health conditions, age, mental health status, and substance use disorders. The current research stays at the descriptive level and addresses implicit bias at the individual level. This article invites nurses to go beyond "the face of the Other" and revisit the ethics of belonging and power.

Solutions to Address Inequity in Diabetes Technology Use in Type 1 Diabetes: Results from Multidisciplinary Stakeholder Co-creation Workshops

Background: Racial-ethnic inequity in type 1 diabetes technology use is well documented and contributes to disparities in glycemic and long-term outcomes. However, solutions to address technology inequity remain sparse and lack stakeholder input. Methods: We employed user-centered design principles to conduct workshop sessions with multidisciplinary panels of stakeholders, building off of our prior study highlighting patient-identified barriers and proposed solutions. Stakeholders were convened to review our prior findings and co-create interventions to increase technology use among underserved populations with type 1 diabetes. Stakeholders included type 1 diabetes patients who had recently onboarded to technology; endocrinology and primary care physicians; nurses; diabetes educators; psychologists; and community health workers. Sessions were recorded and analyzed iteratively by multiple coders for common themes. Results: We convened 7 virtual 2-h workshops for 32 stakeholders from 11 states in the United States. Patients and providers confirmed prior published studies highlighting patient barriers and generated new ideas by co-creating solutions. Common themes of proposed interventions included (1) prioritizing more equitable systems of offering technology, (2) using visual and hands-on approaches to increase accessibility of technology and education, (3) including peer and family support systems more, and (4) assisting with insurance navigation and social needs. Discussion: Our study furthers the field by providing stakeholder-endorsed intervention ideas that propose feasible changes at the patient, provider, and system levels to reduce inequity in diabetes technology use in type 1 diabetes. Multidisciplinary stakeholder engagement in disparities research offers unique insight that is impactful and acceptable to the target population.

Part 5: Essentials of Neonatal-Perinatal Medicine Fellowship: evaluation of competence and proficiency using Milestones

The Accreditation Council for Graduate Medical Education (ACGME) Pediatric Subspecialty Milestone Project competencies are used for Neonatal-Perinatal Medicine (NPM) fellows. Milestones are longitudinal markers that range from novice to expert (levels 1-5). There is no standard approach to the required biannual evaluation of fellows by fellowship programs, resulting in significant variability among programs regarding procedural experience and exposure to pathology during clinical training. In this paper, we discuss the opportunities that Milestones provide, potential strategies to address challenges, and future directions.

Emotion as reflexive practice: A new discourse for feedback practice and research

INTRODUCTION

Like medicine and health care, feedback is a practice imbued with emotions: saturated with feelings relevant to one's identity and status within a given context. Often this emotional dimension of feedback is cast as an impediment to be ignored or managed. Such a perspective can be detrimental to feedback practices as emotions are fundamentally entwined with learning. In this critical review, we ask: What are the discourses of emotion in the feedback literature and what 'work' do they do?

METHODS

We conducted a critical literature review of emotion and feedback in the three top journals of the field: Academic Medicine, Medical Education and Advances in Health Sciences Education. Analysis was informed by a Foucauldian critical discourse approach and involved identifying discourses of emotion and interpreting how they shape feedback practices.

FINDINGS

Of 32 papers, four overlapping discourses of emotion were identified. Emotion as physiological casts emotion as internal, biological, ever-present, immutable and often problematic. Emotion as skill positions emotion as internal, mainly cognitive and amenable to regulation. A discourse of emotion as reflexive practice infers a social and interpersonal understanding of emotions, whereas emotion as socio-cultural discourse extends the reflexive practice discourse seeing emotion as circulating within learning environments as a political force.

DISCUSSION

Drawing on scholarship within the sociology of emotions, we suggest the merits of studying emotion as inevitable (not pathological), as potentially paralysing and motivating and as situated within (and often reinforcing) a hierarchical social health care landscape. For future feedback research, we suggest shifting towards recognising the discourse-theory-practice connection with emotion in health professional education drawing from reflexive and socio-cultural discourses of emotion.

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.

Leveraging Machine Learning to Understand How Emotions Influence Equity Related Education: Quasi-Experimental Study

BACKGROUND

Teaching and learning about topics such as bias are challenging due to the emotional nature of bias-related discourse. However, emotions can be challenging to study in health professions education for numerous reasons. With the emergence of machine learning and natural language processing, sentiment analysis (SA) has the potential to bridge the gap.

OBJECTIVE

To improve our understanding of the role of emotions in bias-related discourse, we developed and conducted a SA of bias-related discourse among health professionals.

METHODS

We conducted a 2-stage quasi-experimental study. First, we developed a SA (algorithm) within an existing archive of interviews with health professionals about bias. SA refers to a mechanism of analysis that evaluates the sentiment of textual data by assigning scores to textual components and calculating and assigning a sentiment value to the text. Next, we applied our SA algorithm to an archive of social media discourse on Twitter that contained equity-related hashtags to compare sentiment among health professionals and the general population.

RESULTS

When tested on the initial archive, our SA algorithm was highly accurate compared to human scoring of sentiment. An analysis of bias-related social media discourse demonstrated that health professional tweets (n=555) were less neutral than the general population (n=6680) when discussing social issues on professionally associated accounts (χ² [2, n=555)]=35.455; P<.001), suggesting that health professionals attach more sentiment to their posts on Twitter than seen in the general population.

CONCLUSIONS

The finding that health professionals are more likely to show and convey emotions regarding equity-related issues on social media has implications for teaching and learning about sensitive topics related to health professions education. Such emotions must therefore be considered in the design, delivery, and evaluation of equity and bias-related education.

Walking the walk: Advice for anti-racist academic leaders

The importance of advancing anti-racism within research has gained recent attention. Academic medical organizations have attempted to increase diversity while seeking structural reforms to advance equity. However, efforts remain constrained while persons from racialized groups continue to experience discrimination. Mental health research is not immune to the experience of inequity. There is ample evidence that mental health research is underfunded compared to other types of health research. In addition, many racialized researchers and research staff have experienced different forms of implicit, explicit, and structural racism and are finding the courage to share their stories. Such experiences of racial trauma have a disastrous impact on the well-being of mental health researchers and adversely influence our overall mission. In this commentary, we also provide tangible and practical suggestions for academic leaders in the field. First, leaders must name racism and resist fragility and defensive reactions when the topic of racism in research is broached. Second, leaders should seek to foster a culture of belonging on teams where feedback from all is welcomed and encouraged. Third, leaders should seek structural change to ensure that teams are diverse and the adverse influence of systemic forms of racial discrimination on research our mitigated. Fourth, leaders must center the voices and perspective of those impacted by racial discrimination when developing, implementing, and evaluating their anti-racism work.

"I Didn't Really Have a Choice": Qualitative Analysis of Racial-Ethnic Disparities in Diabetes Technology Use Among Young Adults with Type 1 Diabetes

Background: Racial-ethnic disparities in diabetes technology use are well documented in young adults (YA) with type 1 diabetes (T1D), but modifiable targets for intervention still need to be identified. Our objective was to explore YA perspectives on technology access and support in routine clinical care. Materials and Methods: Participants were YA with T1D of Hispanic or non-Hispanic Black race-ethnicity from pediatric and adult endocrinology clinics in the Bronx, NY. We conducted semistructured individual interviews to explore how health care and personal experiences affected technology use. Interviews were audio-recorded and transcribed for analysis. We used a modified inductive coding approach with two independent coders and iterative coding processes to improve data reliability and validity. Results: We interviewed 40 YA with T1D: mean age 22 years; 62% female; 72% Medicaid insured; 72% Hispanic; 28% non-Hispanic Black; and mean hemoglobin A1C 10.3%. Themes were categorized into potentially exacerbating and alleviating factors of racial-ethnic disparities in technology use. Exacerbating factors included perceptions that providers were gatekeepers of information and prescription access to technology, providers did not employ shared decision making for use, and YA biases against technology were left unaddressed. Alleviating factors included provider optimism and tailoring of technology benefits to YA needs, and adequate Medicaid insurance coverage. Conclusions: Our results reveal potential intervention targets at the provider level to increase technology uptake among underrepresented YA with T1D. Diabetes health care providers need to be aware of inadvertent withholding of information and prescription access to technology. Provider approaches that address YA technology concerns and promote shared decision making help to mitigate racial/ethnic disparities in technology use.

Recommendations and Guidelines for the Use of Simulation to Address Structural Racism and Implicit Bias

SUMMARY STATEMENT

Simulation-based education is a particularly germane strategy for addressing the difficult topic of racism and implicit bias due to its immersive nature and the paradigm of structured debriefing. Researchers have proposed actionable frameworks for implicit bias education, particularly outlining the need to shift from recognition to transformation, with the goal of changing discriminatory behaviors and policies. As simulation educators tasked with training health care professionals, we have an opportunity to meet this need for transformation. Simulation can shift behaviors, but missteps in design and implementation when used to address implicit bias can also lead to negative outcomes. The focus of this article is to provide recommendations to consider when designing simulation-based education to specifically address racism and implicit bias.

Implicit Bias Recognition and Management in Interpersonal Encounters and the Learning Environment: A Skills-Based Curriculum for Medical Students

Introduction

Students desire instruction in skill development to address both their own implicit biases and bias perceived in the learning environment. Curricula to date achieve strategy identification through reflection and discussion but do not provide opportunity for personally relevant skill development and practice in implicit bias recognition and management. To address this gap, we developed and evaluated a skills-based elective in implicit bias recognition and management focused on learners' own interpersonal interactions, including patient encounters, and perceived bias in the learning environment.

Method

Fifteen first-year medical students completed the nine-session elective over three annual offerings. Each session lasted 1.5 hours. Curriculum development was informed by published frameworks and transformative learning theory. Direct observation of student performances in role-plays and other active learning exercises constituted the formative assessment. Program evaluation focused on the impact of instruction through pre- and posttests, along with analysis of notes taken by the investigative team, including notes on formative assessments.

Results

Students engaged with all aspects of instruction, including role-plays. Pretest/posttest results demonstrated increased self-reported knowledge and comfort in addressing perceived bias. Formative assessment demonstrated students' skill development in safely and respectfully addressing perceived bias in the learning environment without endangering their relationships with supervisors.

Discussion

Skills developed-addressing bias in interpersonal encounters and perceived bias in clinical and teaching encounters-are relevant to learners throughout their careers. This course is relevant to medical students and trainees at various experience levels and could serve as a template for novel, skills-based curricula across health professions.

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.

Advancing Workplace-Based Assessment in Psychiatric Education: Key Design and Implementation Issues

With the adoption of competency-based medical education, assessment has shifted from traditional classroom domains of knows and knows how to the workplace domain of doing. This workplace-based assessment has 2 purposes; assessment of learning (summative feedback) and the assessment for learning (formative feedback). What the trainee does becomes the basis for identifying growth edges and determining readiness for advancement and ultimately independent practice. High-quality workplace-based assessment programs require thoughtful choices about the framework of assessment, the tools themselves, the platforms used, and the contexts in which the assessments take place, with an emphasis on direct observation.

Racial-Ethnic Disparities in Diabetes Technology use Among Young Adults with Type 1 Diabetes

Background: Recent studies highlight racial-ethnic disparities in insulin pump and continuous glucose monitor (CGM) use in people with type 1 diabetes (T1D), but drivers of disparities remain poorly understood beyond socioeconomic status (SES). Methods: We recruited a diverse sample of young adults (YA) with T1D from six diabetes centers across the United States, enrolling equal numbers of non-Hispanic (NH) White, NH Black, and Hispanic YA. We used multivariate logistic regression to examine to what extent SES, demographics, health care factors (care setting, clinic attendance), and diabetes self-management (diabetes numeracy, self-monitoring of blood glucose, and Self-Care Inventory score) explained insulin pump and CGM use in each racial-ethnic group. Results: We recruited 300 YA with T1D, aged 18-28 years. Fifty-two percent were publicly insured, and the mean hemoglobin A1c was 9.5%. Large racial-ethnic disparities in insulin pump and CGM use existed: 72% and 71% for NH White, 40% and 37% for Hispanic, and 18% and 28% for NH Black, respectively. After multiple adjustment, insulin pump and CGM use remained disparate: 61% and 53% for NH White, 49% and 58% for Hispanic, and 20 and 31% for NH Black, respectively. Conclusions: Insulin pump and CGM use was the lowest in NH Black, intermediate in Hispanic, and highest in NH White YA with T1D. SES was not the sole driver of disparities nor did additional demographic, health care, or diabetes-specific factors fully explain disparities, especially between NH Black and White YA. Future work should examine how minority YA preferences, provider implicit bias, systemic racism, and mistrust of medical systems help to explain disparities in diabetes technology use.

Implicit bias in healthcare: clinical practice, research and decision making

Bias is the evaluation of something or someone that can be positive or negative, and implicit or unconscious bias is when the person is unaware of their evaluation. This is particularly relevant to policymaking during the coronavirus pandemic and racial inequality highlighted during the support for the Black Lives Matter movement. A literature review was performed to define bias, identify the impact of bias on clinical practice and research as well as clinical decision making (cognitive bias). Bias training could bridge the gap from the lack of awareness of bias to the ability to recognise bias in others and within ourselves. However, there are no effective debiasing strategies. Awareness of implicit bias must not deflect from wider socio-economic, political and structural barriers as well ignore explicit bias such as prejudice.

Sociocognitive approach to behaviour change for reducing low-value care

Social and cognitive factors that predispose to low-value care (LVC), and strategies for countering them, may be underarticulated in campaigns aimed at reducing LVC. A sociocognitive approach, in addition to traditional knowledge translation strategies, may augment understanding and changing clinician behaviour underpinning LVC.

Faculty and Resident Engagement With a Workplace-Based Assessment Tool: Use of Implementation Science to Explore Enablers and Barriers

PURPOSE

Implementation of workplace-based assessment programs has encountered significant challenges. Faculty and residents alike often have a negative view of these programs as "tick-box" or "jump through the hoops" exercises. A number of recommendations have been made to address these challenges. To understand the experience with a workplace-based assessment tool that follows many of these recommendations, the authors conducted a qualitative study using the Consolidated Framework for Implementation Research (CFIR) to identify enablers and barriers to engagement with the tool.

METHOD

The Psychopharmacotherapy-Structured Clinical Observation (P-SCO) is a direct observation tool designed to assess resident performance during a psychiatric medication management visit. From August 2017 to February 2018, the P-SCO was implemented in the outpatient continuity clinics for second- and third-year residents at Zucker Hillside Hospital/Northwell Health. In February and March 2019, the authors conducted semistructured interviews of participating faculty and residents. Interview guides based on the CFIR were used to capture the enablers and barriers to engagement. Interview transcripts were independently coded. Codes were then organized into themes relevant to the domains of the CFIR.

RESULTS

Ten faculty and 10 residents were interviewed. Overall, participants had a positive experience with the P-SCO. Enabling factors for faculty and residents included the ongoing training, design features of the P-SCO, predisposing beliefs, dedicated faculty time, and the perception that the P-SCO improved verbal feedback quality. Barriers for faculty included checklist length and discomfort with feedback that threatens identity, and barriers for residents included faculty variability in timeliness and quality of feedback and minimal review of the feedback after initial receipt.

CONCLUSIONS

This study demonstrates that the negative experience of faculty and residents with workplace-based assessment tools shown in prior studies can be overcome, at least in part, when specific implementation strategies are pursued. The findings provide guidance for future research and implementation efforts.

Overcoming the Challenges of Direct Observation and Feedback Programs: A Qualitative Exploration of Resident and Faculty Experiences

Problem: Prior studies have reported significant negative attitudes amongst both faculty and residents toward direct observation and feedback. Numerous contributing factors have been identified, including insufficient time for direct observation and feedback, poorly understood purpose, inadequate training, disbelief in the formative intent, inauthentic resident-patient clinical interactions, undermining of resident autonomy, lack of trust between the faculty-resident dyad, and low-quality feedback information that lacks credibility. Strategies are urgently needed to overcome these challenges and more effectively engage faculty and residents in direct observation and feedback. Otherwise, the primary goals of supporting both formative and summative assessment will not be realized and the viability of competency-based medical education will be threatened. Intervention: Toward this end, recent studies have recommended numerous strategies to overcome these barriers: protected time for direct observation and feedback; ongoing faculty and resident training on goals and bidirectional, co-constructed feedback; repeated direct observations and feedback within a longitudinal resident-supervisor relationship; utilization of assessment tools with evidence for validity; and monitoring for engagement. Given the complexity of the problem, it is likely that bundling multiple strategies together will be necessary to overcome the challenges. The Direct Observation Structured Feedback Program (DOSFP) incorporated many of the recommended features, including protected time for direct observation and feedback within longitudinal faculty-resident relationships. Using a qualitative thematic approach the authors conducted semi-structured interviews, during February and March, 2019, with 10 supervisors and ten residents. Participants were asked to reflect on their experiences. Interview guide questions explored key themes from the literature on direct observation and feedback. Transcripts were anonymized. Two authors independently and iteratively coded the transcripts. Coding was theory-driven and differences were discussed until consensus was reached. The authors then explored the relationships between the codes and used a semantic approach to construct themes. Context: The DOSFP was implemented in a psychiatry continuity clinic for second and third year residents. Impact: Faculty and residents were aligned around the goals. They both perceived the DOSFP as focused on growth rather than judgment even though residents understood that the feedback had both formative and summative purposes. The DOSFP facilitated educational alliances characterized by trust and respect. With repeated practice within a longitudinal relationship, trainees dropped the performance orientation and described their interactions with patients as authentic. Residents generally perceived the feedback as credible, described feedback quality as high, and valued the two-way conversation. However, when receiving feedback with which they did not agree, residents demurred or, at most, would ask a clarifying question, but then internally discounted the feedback. Lessons Learned: Direct observation and structured feedback programs that bundle recent recommendations may overcome many of the challenges identified by previous research. Yet, residents discounted disagreeable feedback, illustrating a significant limitation and the need for other strategies that help residents reconcile conflict between external data and one's self-appraisal.

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.

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.