Using Simulation-Based Learning with Standardized Patients (SP) in an Implicit Bias Mitigation Clinician Training Program.

Objectives: To describe the development and refinement of an implicit bias recognition and management training program for clinical trainees. Methods: In the context of an NIH-funded clinical trial to address healthcare disparities in hypertension management, research and education faculty at an academic medical center used a participatory action research approach to engage local community members to develop and refine a "knowledge, awareness, and skill-building" bias recognition and mitigation program. The program targeted medical residents and Doctor of Nursing Practice students. The content of the two-session training included: didactics about healthcare disparities, racism and implicit bias; implicit association test (IAT) administration to raise awareness of personal implicit bias; skill building for bias-mitigating communication; and case scenarios for skill practice in simulation-based encounters with standardized patients (SPs) from the local community. Results: The initial trial year enrolled n = 65 interprofessional participants. Community partners and SPs who engaged throughout the design and implementation process reported overall positive experiences, but SPs expressed need for greater faculty support during in-person debriefings following simulation encounters to balance power dynamics. Initial year trainee participants reported discomfort with intensive sequencing of in-person didactics, IATs, and SP simulations in each of the two training sessions. In response, authors refined the training program to separate didactic sessions from IAT administration and SP simulations, and to increase safe space, and trainee and SP empowerment. The final program includes more interactive discussions focused on identity, race and ethnicity, and strategies to address local health system challenges related to structural racism. Conclusion: It is possible to develop and implement a bias awareness and mitigation skills training program that uses simulation-based learning with SPs, and to engage with local community members to tailor the content to address the experience of local patient populations. Further research is needed to measure the success and impact of replicating this approach elsewhere.

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

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

An Innovative Simulation-based Community-engaged Intervention for Training Research Assistants in Culturally Appropriate Informed Consent.

BACKGROUND: Enrolling under-represented groups in biomedical research remains challenging owing to limited health literacy, historic medical abuses, and mistrust. Addressing such barriers requires scrutiny of informed consent processes and training of research assistants (RAs). Applying simulation methods that are well-established in medical education, Simulation-based Community-engaged Research Intervention for Informed Consent Protocol Testing and Training (SCRIIPTT) engages community members as community advisors (CAs) to train RAs in implementing culturally appropriate approaches, such as addressing difficult issues related to race and power dynamics, into the informed consent training process. OBJECTIVES: To present SCRIIPTT's development, implementation, and preliminary findings. METHODS: Over 12 months, our community-academic partnership 1) introduced SCRIIPTT to the greater community using the Truth & Reconciliation Model, which acknowledges the wrongs of research and offers an apology; 2) deepened understanding of community concerns; 3) developed the intervention; 4) conducted a pilot; and 5) disseminated findings. RESULTS: SCRIIPTT included a comprehensive training manual, scenarios for simulated informed consent encounters, and a 37-item checklist to measure performance. Outcomes include CA and RA satisfaction surveys, and RA performance rating. The checklist adequately measured observable behaviors. RAs reported important gains in knowledge, self-confidence, and cultural competence in conducting informed consent. CAs reported positive experiences, being fully engaged and valued as members of the research team and participants during simulation encounters. CONCLUSIONS: This pilot study demonstrated the feasibility of SCRIIPTT, with preliminary evidence of effectiveness and acceptability. SCRIIPTT offers an innovative approach for community engagement in research training and advancing the skills of RAs in culturally appropriate informed consent.

Global Longitudinal Pathway: has medical education curriculum influenced medical students' skills and attitudes toward culturally diverse populations?

BACKGROUND: The Pathway represents a longitudinal program for medical students, consisting of both domestic and international experiences with poor populations. A previous study reported no significant attitudinal changes toward the medically indigent between Pathway and non-Pathway students. PURPOSE: The purpose of this study was to investigate and differentiate the skills and attitudes of Pathway and non-Pathway students in working with culturally diverse populations by conducting quantitative and qualitative analyses. METHODS: Selected items from a cultural assessment were analyzed using independent t-tests and a proportional analysis using approximation of the binomial distribution. In addition, a qualitative assessment of non-Pathway and Pathway students was conducted. RESULTS: A statistically significant difference was found at the end of Years 2, 3, and 4 regarding student confidence ratings, and qualitative results had similar findings. CONCLUSIONS: Clear and distinct differences between the two studied groups were found indicating the root of this increased confidence may have developed due to exposure to the Pathway program.

Using standardized patients to assess professionalism: a generalizability study.

BACKGROUND: Assessment of professionalism in undergraduate medical education is challenging. One approach that has not been well studied in this context is performance-based examinations. PURPOSE: This study sought to investigate the reliability of standardized patients' scores of students' professionalism in performance-based examinations. METHODS: Twenty students were observed on 4 simulated cases involving professional challenges; 9 raters evaluated each encounter on 21 professionalism items. Correlational and multivariate generalizability (G) analyses were conducted. RESULTS: G coefficients were .75, .53, and .68 for physicians, standardized patients (SPs), and lay raters, respectively. Composite G coefficient for all raters reached acceptable level of .86. Results indicated SP raters were more variable than other rater types in severity with which they rated students, although rank ordering of students was consistent among SPs. CONCLUSIONS: SPs' ratings were less reliable and consistent than physician or lay ratings, although the SPs rank ordered students more consistently than the other rater types.

Assessing professionalism in the context of an objective structured clinical examination: an in-depth study of the rating process.

INTRODUCTION: Professionalism is fundamental to the practice of medicine. Objective structured clinical examinations (OSCEs) have been proposed as appropriate for assessing some aspects of professionalism. This study investigated how raters assign professionalism ratings to medical students' performances in OSCE encounters. METHODS: Three standardised patients, 3 doctor preceptors, and 3 lay people viewed and rated 20 videotaped encounters between 3rd-year medical students and standardised patients. Raters recorded their thoughts while rating. Qualitative and quantitative analyses were conducted. Comments about observable behaviours were coded, and relative frequencies were computed. Correlations between counts of categorised comments and overall professionalism ratings were also computed. RESULTS: Raters varied in which behaviours they attended to, and how behaviours were evaluated. This was true within and between rater type. Raters also differed in the behaviours they consider when providing global evaluations of professionalism. CONCLUSIONS: This study highlights the complexity of the processes involved in assigning ratings to doctor-patient encounters. Greater emphasis on behavioural definitions of specific behaviours may not be a sufficient solution, as raters appear to vary in both attention to and evaluation of behaviours. Reliance on global ratings is also problematic, especially if relatively few raters are used, for similar reasons. We propose a model highlighting the multiple points where raters viewing the same encounter may diverge, resulting in different ratings of the same performance. Progress in assessment of professionalism will require further dialogue about what constitutes professional behaviour in the medical encounter, with input from multiple constituencies and multiple representatives within each constituency.

Learning from mistakes. Factors that influence how students and residents learn from medical errors.

CONTEXT: Trainees are exposed to medical errors throughout medical school and residency. Little is known about what facilitates and limits learning from these experiences. OBJECTIVE: To identify major factors and areas of tension in trainees' learning from medical errors. DESIGN, SETTING, AND PARTICIPANTS: Structured telephone interviews with 59 trainees (medical students and residents) from 1 academic medical center. Five authors reviewed transcripts of audiotaped interviews using content analysis. RESULTS: Trainees were aware that medical errors occur from early in medical school. Many had an intense emotional response to the idea of committing errors in patient care. Students and residents noted variation and conflict in institutional recommendations and individual actions. Many expressed role confusion regarding whether and how to initiate discussion after errors occurred. Some noted the conflict between reporting errors to seniors who were responsible for their evaluation. Learners requested more open discussion of actual errors and faculty disclosure. No students or residents felt that they learned better from near misses than from actual errors, and many believed that they learned the most when harm was caused. CONCLUSIONS: Trainees are aware of medical errors, but remaining tensions may limit learning. Institutions can immediately address variability in faculty response and local culture by disseminating clear, accessible algorithms to guide behavior when errors occur. Educators should develop longitudinal curricula that integrate actual cases and faculty disclosure. Future multi-institutional work should focus on identified themes such as teaching and learning in emotionally charged situations, learning from errors and near misses and balance between individual and systems responsibility.

Tracking the longitudinal stability of medical students' perceptions using the AAMC graduation questionnaire and serial evaluation surveys.

BACKGROUND: This study examined the longitudinal stability of students' perceptions by comparing ratings on similar survey items in three sequential evaluations: end-of-clerkship (EOC), AAMC graduation questionnaire (GQ), and a postgraduate survey (PGY1). METHOD: For the classes of 2000 and 2001, ratings were compiled from EOC evaluations and comparable items from the GQ. For both cohorts, selected GQ items were included in the PGY1 survey and these ratings were compiled. Matched responses from EOC versus GQ and PGY1 versus GQ were compared. RESULTS: Proportions of "excellent" ratings were consistent across EOC and GQ surveys for all clerkships. Comparison of GQ and PGY1 ratings revealed significant differences in only seven of 31 items. CONCLUSION: Student perceptions as measured by GQ ratings are notably consistent across the clinical years and internship. This longitudinal stability supports the usefulness of the GQ in programmatic assessment and reinforces its value as a measure of student satisfaction.

Joint clinical clerkships for osteopathic and allopathic medical students: New England's experience.

Although combined osteopathic and allopathic medical programs are well established for graduate medical education and continuing medical education, little has been published in the literature about such integration at the undergraduate level. The authors describe the preliminary efforts of a joint clinical clerkship program with students from regional osteopathic and allopathic medical schools at a major community teaching hospital in New England. Osteopathic principles and practice are consistently reinforced, exposing students from both medical backgrounds to them. It is hoped that this pilot program serves as a model for developing similar combined programs throughout the United States.

Teaching communication in clinical clerkships: models from the macy initiative in health communications.

Medical educators have a responsibility to teach students to communicate effectively, yet ways to accomplish this are not well-defined. Sixty-five percent of medical schools teach communication skills, usually in the preclinical years; however, communication skills learned in the preclinical years may decline by graduation. To address these problems the New York University School of Medicine, Case Western Reserve University School of Medicine, and the University of Massachusetts Medical School collaborated to develop, establish, and evaluate a comprehensive communication skills curriculum. This work was funded by the Josiah P. Macy, Jr. Foundation and is therefore referred to as the Macy Initiative in Health Communication. The three schools use a variety of methods to teach third-year students in each school a set of effective clinical communication skills. In a controlled trial this cross-institutional curriculum project proved effective in improving communication skills of third-year students as measured by a comprehensive, multistation, objective structured clinical examination. In this paper the authors describe the development of this unique, collaborative initiative. Grounded in a three-school consensus on the core skills and critical components of a communication skills curriculum, this article illustrates how each school tailored the curriculum to its own needs. In addition, the authors discuss the lessons learned from conducting this collaborative project, which may provide guidance to others seeking to establish effective cross-disciplinary skills curricula.

Preparing medical students to teach.

OBJECTIVE: Residents do a significant amount of teaching. Therefore, as medical students prepare for the clinical aspects of their residency, it is also important for them to prepare for their role of physician as teacher. With the goal of offering fourth-year students an opportunity to enhance their teaching skills, an elective was designed that presented them with an opportunity to expand their knowledge base in education, and then apply and practice this new set of knowledge. A week-long elective, Physician as Teacher, was designed to encompass core educational information such as needs assessment of learners, establishing goals and objectives, teaching methods, and evaluation and feedback. This core information was then applied and enriched during an end-of-course teaching presentation. Aside from this course, there is no forum during their undergraduate medical training for the students to acquire knowledge and skills about how to be teachers. DESCRIPTION: The course was developed with the appreciation that application of knowledge is a rich source of learning. The course began with interactive classroom teaching sessions designed to facilitate acquisition of core educational knowledge. Sessions topics included assessment of learner needs, methods of teaching, learning styles, microprecepting, and feedback. Also incorporated were sessions on facilitating small groups, and teaching and learning how to use technology. Those classroom sessions were then enhanced by a complement of sessions that asked the students to apply their new knowledge to clinical situations. Those more application-based sessions included observation and follow-up discussion of clinical teaching and small-group teaching sessions with the goal of developing the students' skills with respect to the teaching and learning process. An end-of-course teaching presentation by each student provided them with a capstone experience of applying the knowledge and skills learned throughout the week. The topic of the teaching presentation was of their choosing, and could incorporate technology. Each student's teaching presentation was videotaped, immediately viewed by the student, and discussed using a structured format of facilitated feedback. DISCUSSION: Students reported that the end-of-course teaching presentation was a rich source of their learning, and an important vehicle for helping them apply and synthesize the new knowledge. Fifteen percent of fourth-year students enrolled in and completed the elective. Seventy-one percent of those students "strongly agreed" and 29% "agreed" that the course provided useful knowledge and skills. Seventy-nine percent "strongly agreed" and 21% "agreed" that their teaching would be better because of the course. Based on comments, the students appeared to feel that the experience of presenting a teaching session at the end of the course was a rich source of their learning, and helped them to apply and synthesize the new knowledge. Students noted, "the teaching project was an excellent idea to see how much we have learned; I never realized what a responsibility we have as residents to teach our peers; I have been enlightened this past week and will now consciously make an effort to share what little information I currently have; I will be a better teacher because I have been given the appropriate tools."