COmmuNity-engaged SimULation Training for Blood Pressure Control
Phase: NA
Conditions: Hypertension
Sponsor: University of Massachusetts, Worcester

 
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Mitigating Implicit Bias in Patient-Clinician Communication in Clinical Encounters:   
A Protocol for the COmmuNity-engaged SimULation Training (CONSULT) Trial 
 
Jennifer Tjia, MD, MSCE1, Michelle Pugnaire, MD1, Joanne Calista, MSW2, Nancy Esparza, 
MEd2, Olga Valdman, MD1, Maria Garcia, MD, MPH1, Majid Yazdani, MD1, Janet Hale, PhD, 
RN, FNP1, Jill Terrien, PhD, ANP-BC1, Ethan Eisdorfer, PsyD1, Valerie Zolezzi-Wyndham, JD3, 
Germán Chiriboga,MPH1, Lynley Rappaport, MEd,MA,MPH1, Geraldine Puerto,BS1, Elizabeth 
Dykhouse, PhD1, Stacy Potts, MD1, Andriana Foiles Sifuentes,PhD1, Sylvia Stanhope,BA1, 
Jeroan Allison,MD,MS1, Vennesa Duodo,BS1, Janice Sabin,PhD4 
 
Institutional Affiliation:  1. University of Massachusetts Medical School, Worcester, MA, USA; 
2. Center for Health Impact, Worcester, MA, USA; 3. Promoting Good, Worcester, MA, USA; 4. 
University of Washington, Seattle, WA, USA 
 
Trial registration:  NCT03375918 
Protocol version: 3.0 (April 20, 2024)  
 
 
 
 
 

 
2 
Abstract  
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 designed 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. Within each academic year, we aimed to 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. However, this design was not feasible beyond the first year of our study because our 
study was paused during the COVID emergency. To maintain clinical staff services in the 
hospital, we were not able to maintain the randomization of training role out to all clinics and 
cohort. We aimed to enroll entire specialty cohorts of IM, FM, and NP trainees over a 3-year 
period, with each academic year constituting an intervention cycle, with 3 cycles of 
implementation corresponding to 3 sequential academic years. Due to COVID, we extended 
enrollment to a 4-year period. Therefore, we analyze these data as cohort study. 
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 

 
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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. 
 
Key words:  implicit bias; medical education; bias awareness; community engagement; simulation 
training   
 

 
4 
INTRODUCTION  
Rationale for the Trial 
 
 
Evidence suggests that healthcare professionals have negative explicit and implicit biases 
toward minority and poor patients,1,2 which can adversely affect clinical decision-making3-6 and 
interpersonal communication.7 Mitigating clinician bias through targeted training in bias 
awareness and interpersonal communication skills is a promising strategy for decreasing 
healthcare disparities for racially, ethnically, and socio-economically disadvantaged persons.8 Few 
rigorously designed trials of communication skills target implicit bias as a factor contributing to 
disparities in health outcomes.9,10  
 
 
To address this gap, we designed a theoretically-grounded, multi-component, training 
intervention trial called “COmmuNity-engaged SimULation Training for Blood Pressure Control” 
(CONSULT-BP). The primary aim of the trial is to improve patient outcomes using a training 
program that combines knowledge acquisition, bias awareness development, and simulation-based 
communication practice with racially and ethnically diverse patients in order to better prepare 
clinicians for patient interactions in which implicit bias may affect healthcare outcomes. The 
clinical focus of the intervention is hypertension management because it represents a challenging 
public health priority,11,12 with healthcare disparities and clinical outcomes mediated, in part, by 
the quality of clinician-patient communication, bias13 and unsatisfactory patient experiences of 
care.14 
 
 
The current educational arsenal to address racism and bias in healthcare has critical gaps, 
notably failing to incorporate personal bias awareness and evidence-based bias mitigating 
strategies into a program of practice and feedback from patients.10 We address these gaps in our 
trial by implementing a multi-component “knowledge, awareness, and practice” training model 
that involves community member and patient representation during the design and 
operationalization of the educational intervention. This protocol report provides a resource for 
others seeking to design a trial that evaluates and implements a training intervention to mitigate 
implicit bias in clinician-patient encounters. 
Objectives 
 
 
The aims of the clinical trial are to evaluate the effect of this 3-part, training program on:  
1. patient blood pressure outcomes, reported in the electronic medical record (EMR); 2. self-
reported patient medication and diet adherence, as measured by the Hypertension Medication 

 
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Nonadherence Scale15 and the Blood Pressure Self-Care Scale;16 3. patient-reported quality of 
provider communication, as measured by the Health Care Climate Questionnaire;17 4. the trust 
sub-scale of the Primary Care Assessment Survey;18 and 5. trainee bias awareness, as measured by 
the Bias Awareness Scale.19  
Version 3.0 updates:  Objectives 2-4 were not possible because the collection of patient self-
reported data was precluded due to the COVID emergency. 
 
INTERVENTION 
Description of the CONSULT-BP Educational Intervention  
Core Educational Elements 
 
 The three (3) core elements of the educational and training intervention include: 1. trainee 
knowledge acquisition about healthcare disparities, implicit bias and racism; 2. trainee awareness 
of personal bias; and 3. provision of skills to mitigate bias, along with an opportunity to practice 
those skills with authentic standardized patient actors. A Standardized Patient (SP) is a person 
carefully recruited and trained to take on the characteristics of a real patient thereby affording 
learners an opportunity to practice and be evaluated on learned skills in a simulated clinical 
environment.  
 
 To build knowledge, we used National Institute of Minority Health and Health Disparities-
funded e-learning modules about health disparities, implicit bias, and patient-centered 
communication skills.20 We also deliver evidence-based practice knowledge about hypertension 
management, because the skills practice cases with SPs focus on hypertension management. To 
develop personal bias awareness, we use the Implicit Association Tests (IAT)21 with results 
feedback to the trainee. To develop skills, we present evidence-based strategies to mitigate bias 
previously tested in a randomized trial by Devine et al.22 Finally, trainees are provided an 
opportunity to practice those bias-mitigating skills using high-fidelity simulated clinical 
encounters with SPs.23 (Figure 1)   
Theoretical Framework  
 
 
The educational intervention and its delivery, conceived in 2017 and prior to more recent 
models for implicit bias education and management, 24 were designed to reflect key features of an 
adaptation of Bennett’s intercultural competency framework.25,26 In this theoretical model, to 
overcome denial about ones’ own implicit biases, learners need to first acquire knowledge and 

 
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understanding about implicit bias. Then, to help learners develop acceptance of the effect of 
implicit bias on healthcare disparities, learners need to move toward integration and recognition 
of implicit bias within themselves and their clinical encounters. The ultimate goal is to motivate 
learners to acquire and apply effective communication skills in situations where implicit bias is 
likely to arise.  
 
  Applying the simulation-based training model of repeated practice and feedback for skills 
acquisition and progression to skill mastery,27 the CONSULT-BP training featured “mock” clinical 
encounters designed to “activate” trainee biases in the clinical care setting. To replicate the 
“authentic” experience of implicit bias in clinical care, the CONSULT-BP intervention developed 
face-to-face simulated clinical encounters with “acting” SPs recruited from local racial and ethnic 
communities as a foundational component of the program. These face-to-face interactions 
provided a “contact-based educational intervention.”26 Contact with groups for which one may 
hold biased attitudes may help reduce such bias.28   
 
METHODS AND ANALYSIS 
Trial Design 
 
 
This was originally designed as a cluster randomized trial of the CONSULT-BP training 
using a stepped wedge design to evaluate the effectiveness of one-time CONSULT-BP training on 
patient outcomes. The original rationale for the stepped wedge design accommodates pre-existing 
training schedules to mitigate the effect of temporal trends in clinical skill proficiency. Within 
cohorts of internal medicine residents, family medicine residents, and nurse practitioner students, 
groups of trainees were intended to be randomly assigned to 1 of 5 training time start dates in a 
given academic year using a stepped wedge design to accommodate pre-existing training schedules 
and mitigate the effect of temporal trends in clinical skill proficiency. It also allows for all trainees 
to be assigned to the intervention, which was a pre-condition of involvement by the participating 
training programs, in order to meet training requirements. This design is statistically advantageous 
because all trainees have control and intervention periods, everyone serves as their own control, 
allowing for within and across participant comparisons based on data collection both before and 
after the intervention.29 Our model randomizes training times to one of five start dates within each 
academic year to accommodate pre-existing training schedules and to mitigate the effect of 
temporal trends in clinical skill proficiency. 

 
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Version 3.0 updates:  The cluster randomized trial design was not feasible beyond the first year 
of our study because our study was paused during the COVID emergency. To maintain clinical 
staff services in the hospital, we were not able to maintain the randomization of training within 
year because the needs of the training program’s provision of clinical services took precedent over 
the didactic training. Therefore, we analyze these data as cohort study. 
Setting 
This trial is being conducted at a single academic safety net hospital system that includes 
clinical delivery sites at the academic medical center, a community hospital, and three outpatient 
centers. Approximately 40% of medical center’s primary care patients are low income and ~27% 
non-white. The surrounding community includes 34% of residents that do not speak English at 
home, 21% are Hispanic/Latinx, and there are large newcomer immigrant and refugee populations. 
The medical center is a major regional training site for medical students, graduate nursing students, 
and postgraduate medical residents. The participating training programs include the internal 
medicine (IM), family medicine (FM) residency training programs, and the Doctor of Nursing 
Practice (DNP) nurse practitioner graduate school program. Participant recruitment started in 
September 2018 and we will enroll trainees and patients until August 2021. Data collection will 
continue until November 2021.  
Version 3.0 updates:  Participant recruitment started in September 2018 and continued until we 
will enroll trainees and patients until August 2022. Data collection continued until December  
2022.  
 
PARTICIPANTS 
Eligibility Criteria 
Trainee Enrollment  
 
 
Training programs assign their own trainees to participate in the intervention. Eligibility 
criteria for inclusion of trainee measures in the trial’s outcomes analysis are: 1. practice at a clinical 
site supported by the medical center’s EMR to allow data collection for BP outcome measurement; 
2. a 15-week clinical look-back period; and 3. no prior completion of the CONSULT-BP 
intervention. Trainees are provided a fact sheet and asked to opt-out of the study if they do not 
want their data used for outcomes analysis. 
Patient Enrollment 

 
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Primary outcomes of blood pressure control are measured at the patient level for patients 
clustered within trainees as reported in the electronic medical record. Patients eligible for inclusion 
in the outcome analysis included being: 1. English-speaking; 2. Non-White racial/ethnic minority; 
3. Medicaid recipient (regardless of race/ethnicity); 4. have hypertension. Exclusion criteria: We 
exclude patients with pregnancy, dementia, schizophrenia, bipolar illness, or other serious medical 
co-morbidity that would interfere with hypertension self-control, including enrollment in hospice. 
Secondary patient-reported outcomes of self-reported adherence and quality of communication 
with providers is measured from a subset of patients meeting the same eligibility criteria who are 
randomly recruited in periods before and after the training intervention. 
Intervention Assignment and Recruitment 
 
 
The educational intervention was integrated into the residency programs in IM and FM, 
and into the curriculum for DNP students. We initially aimed to enroll entire specialty cohorts of 
IM, FM, and NP trainees over a 3-year period, with each academic year constituting an intervention 
cycle, with 3 cycles of implementation corresponding to 3 sequential academic years. Due to the 
COVID emergency, this was extended to 4 years of enrollment across 4 academic years. Within 
the first pre-COVID academic year, we randomized training times to 1 of 5 start dates using a 
stepped wedge design. Our biostatistician used a random sequence generator to assign 5 groups of 
learners, from within each program, to 1 of 5 staggered intervention training dates within an 
academic year.  
Version 3.0 updates:  Due to COVID, randomization to training times within each academic year 
was not possible.  Each training program schedulers assigned the trainees according to availability 
within the learning schedules in order to maintain clinician availability to provide care during the 
COVID crisis.  However, across all years, the program was delivered over two in-person sessions 
(and via virtual teleconferencing during COVID), scheduled five weeks apart, to leverage a spaced 
learning design.30  
 
 
The sessions were designed to minimize the time burden of the intervention on trainees 
outside of the classroom. As such, the in-person training sessions combined multiple educational 
components that trainees completed individually, but as part of an onsite group session. In each 
educational session, components included: “individual” online didactic modules, online IATs, 
face-to-face clinical practice simulation with SPs, and “group-based” facilitated debriefing 
sessions. Originally, training in skills to mitigate the effects of implicit bias detailed by Devine et 

 
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al.22 was addressed as part of the group-based IAT debriefings that preceded case simulations with 
SPs. Each of the two, in-person sessions lasted about four hours. If trainee participants were unable 
to attend one of the sessions due to scheduling conflicts, we provided alternative dates for 
attendance. 
Version 3.0 updates:  After the first year or the intervention and in response to feedback from 
learners and faculty and in light of growing awareness of the need to address learner defensiveness 
in implicit bias education,24 we re-designed subsequent the CONSULT educational program. 
Implicit bias and mitigating skills were updated and reframed based on strategies described by 
Cooper using the RELATE mnemonic:  Respect, Empathize, Listen, Ask about your assumptions, 
Talk and Engage patients in problem solving (RELATE).31 Cooper’s framework is grounded in 
what is known about effective communication between clinicians and patients of different racial 
and ethnic groups and in the Ladder of Inference of Argyris and Senge32,33 about how to interrupt 
unconscious processes that people follow to make decisions. Further theoretical grounding for the 
item domains was drawn from early evidence for bias mitigation skills proposed by Devine et al.22 
These original strategies include: 1) individuation, which relies on preventing stereotypic 
inferences by obtaining specific information about group members34,35 and 2) perspective taking, 
which involves taking the first-person perspective in the individual with whom you are trying to 
communicate. RELATE does not retain two controversial elements of Devine’s original strategies, 
including ‘stereotype replacement’, which involves replacing stereotypical responses for non-
stereotypical responses, and ‘counter-stereotypic imaging’ which involves imagining a 
representative person that goes against a standardized mental picture that is held in common by 
members of a group and that represents an prejudiced attitude;36 these strategies are omitted 
because there is concern they inadvertently perpetuate negative stereotypes.  
Outcome Measures and Data Collection 
Trainee Measures 
 
 
Trainee Demographics. We collect trainee age, gender, race/ethnicity, training year, 
whether they are US or foreign-born, and fluency in another language. 
 
 
Trainee IAT, Explicit Bias Measures, Bias Awareness, and Reaction to the IAT. Trainees 
are asked to complete online Race/Ethnicity IATs [Black/White, Latino/White]21 and 
Race/Ethnicity-Medical Compliance IATs [Black/White, Latino/White].37 Trainees were asked 
about their corresponding explicit beliefs and perceptions of what “other health professionals” 

 
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believe about race/ethnicity and race/ethnicity-related medical compliance in order to assess 
trainees’ perception of their own bias as being “better than average".38 To assess trainees’ reaction 
to the IAT, three questions are included from Howell & Ratliff38 using a 4-point scale (Strongly 
disagree, Disagree, Agree, Strongly Agree) to measure the trainees’ degree of defensiveness to the 
IAT. Trainees also complete a 7-item Bias Awareness Scale, with items assessed on a 6-point scale 
(strongly agree to strongly disagree) and higher scores indicating greater bias awareness.19 In year 
1, these items were collected online during each of the in-person training sessions and included 2 
IATs at each session (total 4 IATs).  
Version 3.0 update:  After the first year or the intervention and in response to feedback from 
learners and faculty and in light of growing awareness of the need to address learner defensiveness 
in implicit bias education,24 we re-designed subsequent the CONSULT assessments to reduce the 
number of IATs requested, we made the IAT an optional component, and we requested completion 
of only one race-compliance IAT.39 
 
 
Assessment of Trainees by SPs. Community SPs complete standardized checklists of 
trainee performance measuring communication skills, perceptions of respect, emotional response, 
concern, empathy, listening skills, involvement in shared decision-making, engagement and 
partnership, BP measurement technique, and global performance. Standardized patient evaluators 
included simulation center standardized patient staff who participated in hypertension 
management clinical simulations with the trainees. Standardized patient evaluators were not 
limited in the number of trainees they could evaluate and provided ratings between September 
2018-April 2022.   
Version 3.0 update:  The evaluation checklist was organized to reflect the RELATE framework.   
Patient Measures  
 
 
The primary trial outcome is the change in BP as reported in the EMR. Clinical 
measurements are collected in the 15-week control period prior to CONSULT-BP training period 
and during a 20-week post intervention period. The main outcome measures in the primary analysis 
will be systolic and diastolic BP (mm Hg) from the EMR. Analyses will stratify BP control as 
defined by the Joint National Commission 840: controlled HTN defined as SBP of <140/90 for 
most patients, or SBP < 150/90 for patients ≥60 years without a diagnosis of diabetes or chronic 
kidney disease, and uncontrolled hypertension as defined as greater than these values.  

 
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Version 3.0 updates: The original study design also included secondary patient self-reported 
outcomes including adherence to visits, diet modification and antihypertensive medication use as 
measured by the BP Self-Care Scale,16 Hypertension Medication Nonadherence Scale,15 and 
quality of communication and trust measured in the Health Care Climate Questionnaire17 and the 
trust sub-scale of the Primary Care Assessment Survey. 18 In year 1, these surveys were 
administered in clinic offices of participating trainees in the 15-weeks before and 20-week after 
the educational intervention. This was not possible after the first year of the trail due to the 
COVID emergency.   
Data Management 
 
 
We conducted data abstractions from the electronic medical record for primary outcomes 
assessment using a system that extracts data from the clinical database, reformats it and stores it 
on a separate analytics server to make querying the database more efficient and extract data without 
impacting clinical flow. Primary data collection from trainee self-report and patient questionnaires 
were entered into an electronic data capture system, RedCAP, using case report forms designed 
for this purpose, with the exception of the IATs which were directly collected by Project Implicit 
via an internet-based interface. Standardized patient assessments of trainee performance in the 
simulation lab are entered into the Learning Space data capture system used for all training and 
evaluation exercises at the clinical simulation lab. 
Statistical analysis 
Version 3.0 updates:  To maintain clinical staff services in the hospital, we were not able to 
maintain the cluster randomized stepped wedge design of training role out to all clinics and cohort 
during the COVID emergency. Therefore, we analyze these data as cohort study. 
 
The first step of statistical analysis was examining the distribution of all data points to 
identify outliers or errors in the data of primary interest.  Unadjusted analysis of categorical data 
was conducted with chi-square tests; analysis of continuous data used analysis of variance.  
Mixed effects regression models were fit to estimate the relative changes of clinical outcomes 
(BP values and clinical cut points) for patients seen by residents in the 6 months before and 6 
months following the intervention periods. Mixed-effect linear regression models (logit models 
for normal and optimal BP categories) were fit with mixed effects for resident ID and for study 
cohort. All mixed-effect models also contained terms for the additional terms to account for 
study composition and potential confounders: study population (race and insurance strata), 

 
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clinical department (Family Medicine vs Medicine), age and sex, and relevant clinical 
comorbidity(diabetes, obesity, hyperlipidemia, coronary artery disease, cerebrovascular disease, 
and tobacco use). In order to determine if the study intervention was differentially effective for 
the different patient groups (ie. white patients with Medicaid and patients of color with either 
private insurance, Medicare, or Medicaid), we modeled interaction terms between 4-level 
population variable and intervention period.  P-values less than 0.05 were considered statistically 
significant. 
Sample size calculation 
 
 
For the primary outcome of BP change, we estimate that each resident will have at least 5 
eligible patients per 5-week training block (assuming trainees see ~25 patients per outpatient 
rotation block, of whom ~40% have HTN (n~10), and of whom ~45% are low income). Thus, each 
trainee will see ~10 eligible patients in the 3-block pre-intervention period, and ~20 eligible 
patients in the 4 block post-intervention period. We estimate there will be approximately 205 
enrolled trainees over a 3 year accrual period, yielding ~205x10 pre-intervention observations 
(n=2050) and 205x20 post-intervention observations (n=4100) for all patients with HTN, and 
fewer (control~1025 and intervention ~2050) for participants with uncontrolled HTN (50-70% in 
minority and poor populations).41 We will have >90% power to detect a 3 mmHg difference in 
patients at control and post-training periods. 
Patient and Public Involvement - Development of the Intervention Content and Design  
A unique feature of this trial was the engagement of academic and community stakeholders 
to design, pilot test and implement the educational and training program. To adapt the core 
educational elements and strategies into a feasible and acceptable intervention, we used a 
participation action research approach in which investigators collaboratively partnered with 
stakeholder participants. The goal was to work together to address system-specific issues affecting 
program operationalization.42 Community stakeholder partners for educational design and delivery 
were racial/ethnic and socioeconomically diverse community leaders representing our local patient 
population. A local community health organization, with whom the study team had a long-standing 
research relationship, served as the community member recruitment liaison. Key academic 
stakeholder partners for educational design were School of Medicine and Graduate School of 
Nursing faculty from our target healthcare system. A separate community-based transformational 
change organization, with extensive experience in staff bias training and who worked closely with 

 
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the medical center administrative leadership, was engaged to help design in-person facilitation 
around implicit bias. These partners worked together to design case simulation scenarios, a trainee 
performance evaluation checklist, and SP training protocols that were integrated into a cohesive, 
replicable training program. Finally, community members were recruited to be SPs, which created 
an opportunity for empowerment and equity, as community SP’s provided direct skills feedback 
to healthcare trainees and contributed their “voice” as equal partners in the team effort to develop 
and refine the simulation scenarios. We sought to understand whether this creative and novel 
approach to communication skills training of healthcare professionals catalyzed the motivation of 
our learners to take their patient communication skills to a higher level of mastery through direct, 
objective, and specific feedback from individuals of color trained as SPs.26,43,44 
Monitoring 
 
 
 The PI, in cooperation with the coinvestigators and the UMassChan Medical School 
Institutional Review Board, are monitoring the safety of the proposed project. We have created a 
data safety and monitoring plan and established formal monitoring procedures to closely monitor 
participant safety, data quality and study progress. A data monitoring committee is not needed 
since the study is minimal risk. 
 
 
Monitoring for protocol adherence will be performed monthly to ensure early identification 
of poor performance. Specific parameters being monitored include psychological harm from the 
intervention, contacting patients who are ineligible for the study surveys; all adverse events are 
reported to the IRB. Our study protocol includes informed consent of the trainees for inclusion of 
their data in the outcome analysis, and informed consent for the patient questionnaires, and a 
Health Insurance Portability and Accountability Act (HIPPA) waiver for use of medical record 
data in the aggregated outcomes analysis. 
ETHICS AND DISSEMINATION 
Safety Concerns 
 
 
We obtained Institutional Review Board (IRB) approval at the UMass Chan Medical 
School. To minimize research-associated risk and to protect the confidentiality of participant data, 
all investigators and staff involved in this project have completed extensive courses and passed 
certifying examination on the protection of human subjects in research through Collaborative 
Institutional Training Initiative training and HIPPA certification. The IRB conducts interim audits 
per their policies and procedures to assure compliance with standards of trial implementation. 

 
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Dissemination plan 
 
 
Patient and organizational stakeholders will significantly contribute to the translation of 
the research findings into lay language. Additionally, our group has long-standing relationships 
with large, community-based organizations and will work closely with these stakeholders to 
develop and activate the infrastructure to disseminate our results through community-based 
outreach and academic venues.  As per funder requirements, we will provide limited access to the 
final trial dataset via contractual agreements assuring data protections and security procedures.  
Furthermore, the protocol has been, and the results of this study will be, submitted to 
ClinicalTrials.gov and peer-review publications. 
DISCUSSION   
In approaching the task of implicit bias education and training in healthcare, a gap exists 
between what is theoretically known to be effective25,26 and current practices. Appreciation of 
evidence that implicit bias exists in healthcare professionals has arguably been one of the most 
challenging aspects of addressing the persistent gaps in healthcare disparities. As modeled by 
Bennett and others,25,26 recognition and self-awareness of bias are the critical first steps in training 
to mitigate implicit bias in healthcare. Building on these priorities, the CONSULT-BP program 
specifically targets these first stages in the learning process of bias mitigation for healthcare 
professions.  
 
 Our effort to implement theoretically sound and novel approaches to clinician skill 
building for bias mitigation and improved patient-clinician communication across intercultural 
differences holds important implications for public health. While CONSULT-BP focuses on 
hypertension, the CONSULT-BP model is readily adaptable to other diseases, such as COVID-19, 
in which decisions for testing are emerging as being subject to bias.45 This adaptability of the 
CONSULT-BP model is as important as disparities in healthcare access and outcomes for racial, 
ethnic and poor populations is a persistent problem. Further, the Centers for Disease Control and 
Prevention recommends bias awareness and mitigation skills to address the public health crisis of 
COVID-19.46 To date, the domain of educational interventions for teaching about implicit bias in 
healthcare remains ripe for development. The CONSULT-BP protocol contributes useful insights 
into the design of bias education and training models for healthcare professionals, and provides a 
roadmap for others who share these goals and want to advance their own efforts.  
 

 
15 
ACKNOWLEDGEMENTS We would like to thank the community advisors, standardized 
patients, and trainees for their generous contributions to this project. 
DISCLOSURES OF CONFLICT The authors have no competing interests to disclose. 
CONTRIBUTORS  JT:  conception and design of study, acquisition of study data, drafting and 
critically revising the manuscript; NE, JH, LR, JT, JC, GC, GP, VD, SS, AFS: Acquisition of study 
data, drafting and critically revising the manuscript; MP, OV, MG, MY, ED, EE, SP: conception 
and design of study, critically revising the manuscript; JS:  conception and design of study, drafting 
and critically revising the manuscript. 
FUNDING SOURCE Research reported in this manuscript was supported by the National 
Institute of Minority Health and Health Disparities of the National Institutes of Health under 
award number R01MD011532. The funder had no role in the study design, collection, 
management, analysis and interpretation of data; writing of the report; and the decision to submit 
the protocol for publication. 
DISCLAIMER The content is solely the responsibility of the authors and does not necessarily 
represent the official views of the National Institutes of Health. 
NAME OF IRB GRANTING INSTITITION   University of Massachusetts Medical School 
 
 
PRIOR PRESENTATIONS An earlier version of this paper was presented at the 12th Annual 
Conference on the Science of Dissemination and Implementation, Arlington, VA. December 2019 
 
 

 
16 
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FIGURE  
 
Figure 1. The CONSULT-BP intervention model