Minimizing Defensiveness in Clinician Education about Implicit Bias: Lessons Learned from a Community‐Engaged Randomized Clinical Trial
Authors: Sabin J. , Calista J. , Dykhouse E. , Eisdorfer E. , Foiles A. , Garcia M. , Hale J. , Puerto G. , Rappaport L. , Terrien J. , Valdman O. , Yazdani M. , Tjia J. 
Published: August 2020

Research Objective

Clinicians’ implicit bias can affect quality of healthcare delivery and contribute to healthcare disparities. How to design an educational intervention to equip clinicians with skills to mitigate implicit bias without inducing defensiveness is unclear. COmmuNity‐engaged SimULation Training for Blood Pressure Control (CONSULT‐BP) Trial is a 5‐year clinical trial educational intervention designed in collaboration with racial, ethnic, and socioeconomically diverse representatives of the local patient community. CONSULT evaluates clinician trainee awareness of and defensiveness about implicit bias pre‐ and postexposure to a face‐to‐face simulation training with standardized patients (SPs) from local racial and ethnic communities.

Study Design

Pre‐post analysis of trainee bias awareness and defensiveness in the context of a clinical trial that evaluates the impact of an educational intervention to improve clinicians’ interaction skills with diverse populations. Participants completed two, in‐person educational sessions, 5 weeks apart. Learning components included the following: online modules on health disparities, implicit bias, and patient‐centered care; and face‐to‐face simulation encounters with diverse SPs. Four Implicit Association Tests (IATs) were used to measure implicit and explicit bias, and to promote self‐reflection. We measured pre/post bias awareness using a 7‐item Bias Awareness Scale and defensiveness using a 3‐item pre/post measure of reaction to feedback on implicit bias scores. We also collected trainee feedback about the educational experience.

Population Studied

Graduate medical and nurse practitioner trainees, including internal medicine, family medicine residents, and nurse practitioner students. We present preliminary findings from CONSULT year 1 cohort (N = 86).

Principal Findings

Both before and after, the intervention participants slightly agreed that they are objective that bias does not affect their decision‐making, disagreed that society treats all groups equally, and that all people have equal opportunity. After the intervention, participants were significantly more likely to disagree with the statement that bias is no longer a problem in patient care (P = .00). In response to feedback on their IAT scores, participants were more likely to agree that the IAT reflects “something about my thoughts or feelings, unconscious or otherwise” (48% pre, 54%, post). Preintervention, 76% agreed that “the IAT captures something important about me” but only 58% agreed postintervention. When asked if the IAT reflects something about their “automatic thoughts and feelings” concerning racial/ethnic bias, 75% agreed preintervention and 65% agreed postintervention. Qualitative feedback from trainees reported that the intervention was a burden on their, taking numerous IATs was redundant, and identified an unmet need to address patient bias toward medical providers.

Conclusions

Defensiveness about implicit bias scores increased after exposure to our educational program to mitigate implicit bias. Trainees identified challenges with our educational approach and study design.

Implications for Policy or Practice

We learned of the need to include trainee participants during the design phase of this type of training experience and refined our educational intervention for subsequent cohorts. Without sacrificing essential elements of education, investigators amended the study for years 2‐5 to a single session, one IAT per participant, streamlined content in educational modules and included more in‐person education by an educator with the experience and skills needed to facilitate discussion on this highly charged and complicated topic.

Primary Funding Source

National Institutes of Health.