A Model to Engage Learners in Discussions on Health Equity and Implicit Bias

Joel Amidon, Prisma Health

Mayra Alicia Overstreet Galeano, MedNorth Health Center

David C. Brendle, MAHEC, Boone North Carolina

Yee Lam, University of North Carolina at Chapel Hill

Jessica Waters Davis, University of North Carolina-Chapel Hill

Kalpana Panigrahi, Interfaith Medical Center

Key Statement: Exploring implicit bias early in health education training, even when done quickly, carries the potential to positively impact how future healthcare providers practice and promote health equity through culturally competent care.

Introduction

Implicit bias plays a large role in the delivery of healthcare in the United States (Institute of Medicine, 2003). Healthcare professionals who are aware, or are made aware, of their personal implicit biases, are more likely to address health disparities in both individual clinical settings as well as healthcare systems (Edgoose et al, 2019). Although there is value in everyone having discussions of implicit biases, having conversations, and exploring implicit bias early in health education training carries the potential to impact how future healthcare providers practice and encourage culturally competent care that promotes health equity.

Discussing implicit biases within the clinical learning environment is often a difficult task due to time constraints, and many healthcare educators feel under-prepared to broach this subject with their learners. Time, lack of expertise, and discomfort with integrating discussion into precepting sessions are just a few of the barriers identified by our colleagues that prevent initiating or furthering these discussions.

One-Minute Preceptor for Health Equity and Implicit Bias

The University of North Carolina Faculty Development Fellowship Fellows Educational Collaborative, comprised of academic medical school and residency faculty from across the country developed a model to improve teaching and patient care related to health equity and bias in a clinical context. A primary goal of this model is to create a safe space for discussion and exploration of implicit bias and health equity.

Using the framework of the One-Minute Preceptor (Neher et al., 1992; Zakrajsek, 2015) we developed a precepting model to initiate and facilitate clinically relevant conversations around implicit bias and health equity. The One-Minute Preceptor for Health Equity and Implicit Bias utilizes the 5 micro-skills of its predecessor while refocusing the conversation:

1. Get a commitment

a. What individual or systemic implicit biases may have impacted

this patient's health or healthcare?

b. What systemic or structural drivers of health may be impacting

this patient’s health?

2. Probe for supporting evidence

a. What led you to the identification of this example?

3. Teach a general rule

a. How could you help mitigate this bias or inequity?

4. Provide positive feedback

a. Summarize key findings and provide positive feedback.

5. Correct errors

a. What is a key takeaway from the encounter?

We found that the implementation of this framework creates a space for a rich and reflective conversation and can be applied in clinical settings (inpatient/outpatient) in under two minutes. The One-Minute Preceptor model allows the learner to reflect on their biases without the preceptor having to be an “expert” on the specific clinical or psychosocial topic discussed. This model addresses the concerns of many preceptors (e.g., time, discomfort) when bringing up this topic.

Approach

We based the framework of this precepting model on the concept of microskills from the One-Minute Preceptor. We also sought feedback and guidance from colleagues engaged in broader diversity, equity, and inclusion work to optimize phrasing for the microskills questions as well as curate appropriate resources to include in the guide. Following IRB approval, the faculty members in this Education Collaborative, as well as residency leadership at our programs, were involved in the initial pilot to incorporate this model into clinical precepting. In the outpatient setting, preceptors were asked to apply the implicit bias and health equity precepting model to at least one patient encounter per resident during a clinic session. In the inpatient setting, preceptors were asked to use the model with the primary resident at least once during a patient’s hospitalization.

We gathered qualitative feedback and examples of how preceptors used the model. Preceptors incorporated this model in a wide variety of ways during various points in the precepting encounter. If bias and/or health equity topics arose organically during a clinical precepting encounter, the model also prompted preceptors to signpost and expand on them. We also gathered qualitative feedback from residents which was overwhelmingly appreciative and enthusiastic.

After this initial pilot, we created a 3 x 5-inch card of the precepting framework with microskills on one side and resources for faculty and learners on the reverse side. The guide can be carried by the preceptor or displayed in shared precepting space for easy reference. We officially launched the precepting model to the entirety of our teaching faculty via an orientation presentation which included a pre-implementation survey to gauge current state of comfort/frequency of discussion around these topics while precepting. Follow up emails and conversations occurred over the next 6-week period, and faculty received a post-implementation survey to evaluate the effect of the tool on preceptors’ incorporation of and comfort with discussing implicit bias and health equity in their clinical teaching. A control group consisted of three additional family medicine residencies who did not received access to the implicit bias precepting tool until six-weeks after the follow-up survey.

Findings

The One-Minute Preceptor for Implicit Bias and Health Equity precepting tool was introduced to and piloted at seven institutions (five family medicine residencies, one internal medicine residency, and one medical school. The initial intervention group had N=41 respondents (61 % female, 82.9% white) and the control N=16 (62.5% female, 93.8% white). The impact of implicit bias on health outcomes for all respondents was ranked as high (2.75 out of 3). The importance of conversations during precepting about bias and equity was also ranked as high (4.23 out of 5). At baseline, 65.6% of all respondents reported incorporating implicit bias into precepting.

A 6-week follow-up survey had an N=14 (34.1%) in the intervention group and N=8 (50%) in the control group. There was no change in the frequency of incorporating implicit bias and health equity in precepting for the control group (N=8 paired analysis) or intervention group (N=14). There was an increase in respondents’ comfort of incorporating implicit bias and health equity in precepting for the intervention group (N=14; pre 3.30 out of 4.00; post 3.79 out of 4.00) but no change in the control group (N=8 for paired analysis), although the sample size for this pilot study was too small to infer statistical significance.

Qualitative responses revealed the following themes: increased awareness, self-reflection, empowerment, and advocacy. Several faculty members shared that using this tool in precepting had increased their recognition of their own biases and assumptions when practicing clinically. Feedback from residents was positive, with one resident adding “I now ask these questions to myself even when I am seeing a patient without you [preceptor].”

Discussion

This pilot study suggests that the micro-skills from the One-Minute Preceptor model can be successfully adapted to provide a time-efficient framework for educators to discuss health equity, racial bias, and other implicit biases in the clinical setting. Although faculty and learners may still experience hesitation around how to effectively discuss bias and health equity, the model offers a structure for beginning these conversations, which is a necessary first step toward recognizing and addressing bias and disparities in clinical medicine. Limitations of the pilot include the lack of randomization, low number of participants, attrition rate, and possible response bias. Future steps include further revision of the tool, presenting these results at a national teaching conference, outreach to institutions interested in implementing this model, and conducting further research with a larger number of participants.

Discussion Questions:

1. 1. How do you currently discuss bias and health equity with your learners? If you do not do so currently, what makes it challenging to discuss equity and bias?

2. Describe how the one-minute preceptor model for health equity and implicit bias might be adapted to fields other than health to be used to frame group reporting out following a small group discussion within a course.

3. How might we frame discussions and resources regarding equity and bias so that students are better suited to have informed discussions on these topics?

References

Edgoose, J., Quiogue, M., & Sidhar, K. (2019). How to Identify, Understand, and

Unlearn Implicit Bias in Patient Care. Family practice management, 26(4),

29–33.

Institute of Medicine (US) Committee on Understanding and Eliminating Racial

and Ethnic Disparities in Health Care, Smedley, B. D., Stith, A. Y., & Nelson, A. R.

(Eds.). (2003). Unequal Treatment: Confronting Racial and Ethnic Disparities

in Health Care. National Academies Press (US).

Neher, J. O., Gordon, K. C., Meyer, B., & Stevens, N. (1992). A five-step "microskills"

model of clinical teaching. The Journal of the American Board of Family

Practice, 5(4), 419–424.

Zakrajsek, T. (August 25, 2015). The one-minute preceptor applied to a variety of

situations. The Scholarly Teacher.

About the Authors