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

Abstract

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.

Racial Implicit Bias and Communication Among Physicians in a Simulated Environment

“…To our knowledge, although simulations incorporating implicit bias have been developed for genetic counselors, nurses, and medical residents and nurse practitioners, no published studies have measured the association of racial implicit bias with physician communication skills from the perspectives of blinded SPs, who would approximate the perspective of patients in actual clinical settings. Additionally, although prior simulation studies incorporating implicit bias intentionally selected SP identity factors, such as race or gender identity, none reported integration of cognitive stressors common to clinical environments . In this pilot study, we created a simulation that precipitates the negative influence of racial implicit bias on physician communication skills: features potentially contributing to its success were the realistic nature of the simulation and inclusion of cognitive stressors common to clinical environments …”

“…These associations are consistent with extant literature on physician communication and racial implicit bias. 1 , 2 , 3 , 4 To our knowledge, although simulations incorporating implicit bias have been developed for genetic counselors, 56 nurses, 57 and medical residents and nurse practitioners, 36 no published studies have measured the association of racial implicit bias with physician communication skills from the perspectives of blinded SPs, who would approximate the perspective of patients in actual clinical settings. Additionally, although prior simulation studies incorporating implicit bias intentionally selected SP identity factors, such as race or gender identity, none reported integration of cognitive stressors common to clinical environments.…”

“…The intentional deception we undertook by not telling participants about the racial implicit bias component of the study was necessary so that physicians would participate with as close to their natural clinical practice behaviors as possible; it has been undertaken in various studies exploring physician implicit bias. 58 , 59 , 60 , 61 Previous studies reported negative reactions to implicit bias being a part of simulations, 36 , 57 which highlights the importance of debriefing with a content expert, especially after intentional deception is used. The IAT is resistant to faking 62 and is therefore well suited for the end of the simulation, so as to not prime participants to the purpose of the study.…”

“…Racial Bias and Physician Communication in a Simulated Environment simulation studies incorporating implicit bias intentionally selected SP identity factors, such as race or gender identity, none reported integration of cognitive stressors common to clinical environments. 36,56,57 In this pilot study, we created a simulation that precipitates the negative influence of racial implicit bias on physician communication skills: features potentially contributing to its success were the realistic nature of the simulation and inclusion of cognitive stressors common to clinical environments. 37,44,45 Participants deemed the simulation realistic and were able to complete all procedures online.…”

“…Few simulations focus on physician implicit bias and its impact on physician communication skills, and none to our knowledge quantify the association between implicit bias and communication skills. Clinical environments are often replete with cognitive stressors, including clinical ambiguity, stress, time constraints, and interruptions; implicit bias is more likely to negatively impact a clinical encounter in the setting of these cognitive stressors .…”