Responding to Interprofessional Microaggressions: Bystander Training—A Virtual Simulation Curriculum for Internal Medicine Residents

Abstract

Introduction

Literature demonstrates the detrimental impact of discrimination and microaggressions at personal and institutional levels in the health care workplace. Residents in our program requested curricula to help with addressing manifestations of bias. In response, we designed and implemented an adaptable and reproducible 4-hour virtual simulation session aimed at helping residents identify and constructively respond to microaggressions.

Methods

This curriculum, influenced by a preceding needs assessment, was delivered to 68 senior internal medicine residents. It began with a didactic overview to establish foundational knowledge of bias. This was followed by a workshop focused on strategies to address microaggressions. The session culminated with skills practice in a virtual simulation activity where learners addressed microaggressions as bystanders in realistic case scenarios employing simulated participants. We administered pre- and postevaluation individual key-linked surveys assessing learner confidence in responding to microaggressions.

Results

A total of 68 residents participated in the curriculum over two academic years, 27 of whom provided complete data for analysis. Overall, there was a statistically significant increase in learner confidence identifying microaggressions. As both a bystander and target/recipient of microaggressions, there were statistically significant increases in learner confidence addressing gender-based microaggressions, race-based microaggressions, and microaggressions reflecting other types of bias. Furthermore, there were statistically significant increases in learner confidence addressing microaggressions in low-acuity contexts, high-acuity contexts, across interprofessional disciplines, with a supervisor, and with a supervisee.

Discussion

Our virtual experiential curriculum on responding to microaggressions can help increase learner confidence in addressing microaggressions.

Educational Objectives

By the end of this activity, learners will be able to:

• 1.Recognize and respond to various types of microaggressions as bystanders in the workplace.
• 2.Evaluate and reflect on personal behavioral changes and developments in addressing microaggressions after participating in the curriculum.
• 3.Apply at least one strategy during a role-play scenario with simulated participants to address an interprofessional microaggression as a bystander.
• 4.Develop an understanding of their own preferred strategies when approaching microaggressions.

Introduction

Implicit bias manifests in many ways, including stereotypes, discrimination, and microaggressions.¹ Dr. Chester Pierce first coined the term microaggression, followed by Dr. Derald Wing Sue, who expanded on his definition as routine verbal or behavioral insults, both intentional or unintentional, that communicate hostile, derogatory, or negative offenses towards members of marginalized groups.^2–4

Microaggressions, along with other experiences of discrimination and segregation, have a long history in academic medicine.⁵ For example, women often encounter bias related to pregnancy and childcare.⁶ Physicians of color tend to experience the assumption of their not being a doctor and receive lower compensation.⁷ Notably, microaggressions represent only one of many expressions of implicit bias to address.

Tackling microaggressions in the medical setting may improve the well-being of our colleagues and increase provider retention. Perceived workplace discrimination is associated with decreased job performance and satisfaction.^8,9 Additionally, experiencing bias is associated with increased levels of stress and long-term negative psychological and physical health detriments.^4,6,9,10 Nunez-Smith and colleagues described an association between physicians who left a job due to discrimination and lower career satisfaction.¹¹ Their study also found that physicians who self-identified as nonmajority were more likely to have left at least one previous job due to discrimination. To recruit, retain, and nurture a diverse medical workforce, it is imperative that we acknowledge and address discrimination within the workplace.

Residency is a time when physicians experience and learn to navigate bias.¹² In our internal medicine residency program, trainees expressed a desire to learn how to address manifestations of bias in a productive and timely way without negatively affecting the work environment. To design a relevant curriculum, we first undertook a needs assessment. Survey answers demonstrated a high prevalence of experienced and observed microaggressions with low bystander response rates. Respondents also believed that utilizing a framework when responding to microaggressions would be helpful. Prior curricula have provided structured frameworks to empower individuals with effective strategies and responses to address and navigate the complexities of microaggressions in diverse social interactions.^13–19 Our curriculum incorporates a set of suggested approaches to microaggressions known as the LIFT (lights on, impact vs. intent, full stop, and teach) framework, which was developed by some of our authors during their time in the Mid-Career Faculty Leadership Program at the Boston University Chobanian & Avedisian School of Medicine and was influenced by the work of Dr. Derald Wing Sue. Our low-stakes formative teaching workshop is designed to fill the gap described above for internal medicine residents. We have employed the talents of simulated participants in accessible virtual simulation sessions to teach the LIFT framework.

MedEdPORTAL's Anti-racism in Medicine Collection has many curricular resources to teach learners particularly about unconscious bias.^13–19 Most of these resources employ didactic sessions combined with case-based learning and response frameworks to increase learner confidence in responding to microaggressions and mistreatment. Our curriculum adds to this body of work by incorporating an element of experiential learning as well as uniquely incorporating simulated participants on a virtual platform. High-fidelity medical simulations enhance learning through feedback and repetitive practice in a controlled environment with realistic scenarios.²⁰ Virtual platforms have proven to be an effective tool in medical education, offering an accessible and immersive platform for students to hone their communication skills.²¹ Learners in our session participate in live simulations of cases inspired by commonly discussed interprofessional microaggressions as well as by their own experiences shared in the needs assessment. Furthermore, employing simulated participants allowed residents to practice responding to microaggressions in real time. The virtual platform removes potential obstacles for participants such as coordinating physical space and commuting barriers.

Methods

Curricular Context

The LIFT workshop was initially developed to address the educational gap in managing microaggressions among faculty. The workshop combined a lecture and interactive role-play in a concise yet effective 1-hour session, enhancing participants’ awareness and confidence in addressing microaggressions. The workshop's initial effectiveness was gauged by pre- and postsurvey assessments that showed participants were significantly more comfortable identifying and responding to microaggressions after participating in the workshop. According to survey comments, the workshop was well received by faculty participants, and it has since been delivered multiple times to various audiences.

Virtual Simulation Curriculum

We attempted to establish a psychologically brave space in our simulation design by setting ground rules at the start of the session and explicitly coaching facilitators to support an environment conducive for learners to take risks by assuming the best intent from everyone. We hoped these guidelines would allow learners to explore their own communication styles while promoting diversity of opinion, accountability, shared experiences, collaborative learning, and mutual understanding.²² We approached this design virtually since the implementation of our curriculum occurred during the COVID-19 pandemic. Our facilitators were a group of diverse volunteers who were familiar with the LIFT mnemonic of strategies through facilitator orientations designed for this session or other institutional efforts. We also suggested that our faculty read “Disarming Racial Microaggressions: Microintervention Strategies for Targets, White Allies, and Bystanders.”⁴ No prerequisite knowledge was needed by the learners.

Appendix A includes logistical information regarding the virtual structure of the 4-hour curriculum. The first hour introduced the concept of bias, reviewed evidence-based literature, and described the local prevalence of bias in a didactic format. The second hour was a workshop highlighting the LIFT mnemonic of strategies in responding to microaggressions as a bystander. The third and fourth hours consisted of the simulation activity. Acknowledging the emotional vulnerability inherent in this activity, we recruited facilitators to colead sessions in pairs to provide each other peer support for challenging questions and discussions.¹⁴ We delivered the curriculum to senior internal medicine residents during their dedicated time for classroom education called academic half day. Based on their block scheduling, a quarter of the group (approximately 12 residents or fewer) would have their academic half day in any given week. In order to capture the whole group of senior residents, we administered the session weekly over 4 weeks.

Prior to the session, facilitators went through a 1-hour training introducing them to the curriculum. The recruited simulated participants also underwent an orientation to the cases with an opportunity to do a read-through and ask questions (Appendix B). An example shared in the needs assessment (Appendix C) was adapted as a case for the simulation. Cases were designed to be relevant, realistic, engaging, challenging, and instructional, as outlined in the conceptual framework for didactic and simulated participant case development of Kim and colleagues.²³

At the start of the curriculum, we provided learners with a hyperlink to the optional individual key-linked presession survey that would be used in comparison to their postsession survey as a means of evaluating our curriculum (Appendix D). We designed the surveys to reflect the contexts in which we hoped our residents would feel more confident addressing microaggressions after concluding our session. The survey was made up of multiple-choice questions and a small number of open-ended questions. The multiple-choice questions asked about confidence in responding to microaggressions in various contexts. The open-ended questions asked learners to provide strategies for responding to microaggressions (scored as zero, one, or two strategies offered) and thoughts on provider impact (scored based on whether two impacts were identified). The pre- and postsession surveys were created solely for this curriculum and had not been previously published. Lower values for the multiple-choice questions indicated increased confidence/likelihood.

We delivered the first hour of the curriculum virtually via slideshow to the learners (Appendix E). Facilitator slide notes were available for each slide to help maintain consistency in the content conveyed each week (Appendix F). The second hour was a workshop delivered through a combination of slides and two virtual breakout groups. We introduced learners to strategies that could be used to respond to microaggressions. In smaller groups, learners reviewed sample cases to identify the microaggression, describe the strategy they would like to apply to address the microaggression, and explain how they would apply that strategy (Appendix G). One of the cofacilitators was available in each breakout group. Small groups were then brought back to the large group to debrief their discussions of strategies and challenges.

For the simulation part of the session (the third and fourth hours), a local staff member, who assisted with simulated patient-based education for trainees across the institution, recruited simulated participants for our curriculum. Given the virtual nature of recruitment, the simulated participant pool to select from had broadly expanded, and our coordinator was able to employ simulated participants from across the country. Based on our case design, we specifically asked for the following simulated participant demographics: (1) simulated participant of any demographic (case A), (2) female simulated participant (case A), (3) White simulated participant (case B), and (4) non-White simulated participant (case B). The demographic requests for case B were based on the majority group seen in medicine at the time as described by American Associated of Medical Colleges 2018 US physician workforce data.²⁴ The cases were designed to occur in an inpatient medical setting (Appendices H and I). All learners experienced both cases A and B either as an observer or as part of the simulation. We applied a modified version of the “down the line” technique where the first learner for a case started the scenario from the beginning and each subsequent learner for the same case could elect to start at the beginning or at any point later in the case.²⁵ Each learner was expected to actively engage in at least one of the two encounters. The learners were split into two virtual rooms with ideally up to six learners per room. During the third hour, one group worked through case A, and the other group worked through case B. In the following fourth hour, the simulated participants switched virtual rooms. The learners who did not engage in the case during the third hour engaged in the case during the fourth hour. We had two facilitators available for each virtual room.

Facilitators were provided with simulation-specific guides (Appendices J and K) on how to run these hours and accommodate learner needs. Generally, the first learner to engage in the case would start from the beginning of the script and would be asked to apply one or more of the strategies discussed earlier in the session to respond to the microaggression(s) observed in the scenario. Each learner had the chance to pause the scenario, poll their peers for suggestions, restart the scenario from a specific time point, or restart the scenario altogether. After the case, time was allocated for immediate reflections and feedback. Each subsequent learner who engaged in a case had the same options as the first learner but could additionally choose where they would like to start the scenario having already seen the entire script. After the designated learners engaged in the scenario, there was time dedicated for another debrief within the group, with questions available in the facilitator guide to prompt discussion. Learners not engaged in the simulation turned their cameras and microphones off to simulate a separate space for those actively involved, enhancing the realism of the scenarios. During the 2 hours dedicated to the simulation, a staff member, distinct from the facilitators, managed the technological features (breakout groups, time checks, simulated participant movement between groups, etc.).

At the conclusion of the activity, we provided learners with a hyperlink to the optional individual key-linked postsession survey (Appendix D). We employed nonparametric sign testing for the noncontinuous, ordinal data with significance set at p < .05. The evaluation procedures were deemed exempt by the Boston Medical Center and Boston University Medical Campus Institutional Review Board (IRB# H-37309, approved February 15, 2018).

Results

Of those who responded to the needs assessment, 86% reported that they would find it helpful to have a framework to apply when responding to microaggressions, and 77% said that they would find it helpful to have a session dedicated to the practice of responding to microaggressions. A total of 68 residents participated in the curriculum over two academic years, 27 of whom provided complete data for analysis in the Table, where lower values on a 4-point scale indicate increased confidence.

Table. Results of Sign Tests Comparing Pre-Post Data (N = 27).

Overall, we observed a statistically significant increase in learner confidence identifying microaggressions. We noted statistically significant increases in learner confidence addressing gender-based microaggressions, race-based microaggressions, and microaggressions reflecting other types of bias both as a bystander and target/recipient of microaggressions. In terms of the workplace setting, we saw statistically significant increases in learner confidence addressing microaggressions in low-acuity contexts, high-acuity contexts, across interprofessional disciplines, with a supervisor, and with a supervisee. We also discerned a marginally significant increase in learner belief that trainees should practice addressing microaggressions in the health care setting. Additionally, learners evaluated and reflected on personal behavioral changes and developments in addressing microaggressions, demonstrating a statistically significant increase in their likelihood of addressing interprofessional microaggressions related to race in the health care setting. We did not observe a statistically significant change in learner likelihood of addressing microaggressions related to gender or other forms of bias.

For the textual analysis, we observed no statistically significant differences between the pre- and postevaluation surveys in learners’ strategies for addressing microaggressions and learners’ perceptions of the ways microaggressions affect providers in the health care workplace (p > .05). While facilitators were instructed to ensure all learners applied at least one strategy during the role-play scenarios with simulated participants to address an interprofessional microaggression as a bystander, we did not explicitly verify if learners accomplished this objective.

We also gleaned that employing simulated participants was important for a more realistic experience given the qualitative feedback responses:

• •“The simulations were uncomfortable, but that's the point of them. I really appreciated having [simulated participants] to do the scenarios with instead of acting them out ourselves.”
• •“Oh boy. This session made me feel very uncomfortable. I think it is so important to practice these skills in these ‘real-life’ scenarios, because we all have these grandiose ideas about how we ‘would like’ to respond, but it is so much tougher in the moment.”
• •“Maybe more explicit teaching about how to address biases when you're someone who doesn't identify with the group that is being biased against and how strategies differ if you identify with the group experiencing the bias or not.”
• •“I appreciated the opportunity to practice and observe some of the scenarios and practice some of the techniques of response and appreciated the ‘safe space’ that was created by facilitators and [simulated participants]. I recommend continuing this session in the future!”
• •“I appreciated how it built in terms of us listening more at first, then giving thoughts on specific scenarios, then acting in role play scenarios.”
• •“Enjoyed the cases. This should really be more of a longitudinal curriculum as it was a lot to pack into 4 hours given the gravitas and heavy-handed nature of the topics being handled.”

Discussion

Our curriculum on responding to interprofessional microaggressions is unique in several ways: It can be adapted for the specific needs of any graduate medical training program; it can be implemented on a virtual platform; it employs simulated participants to recreate scenarios; and it utilizes a scripted facilitator guide. Our results indicate that this experiential learning session enhanced learners’ confidence in recognizing and responding to various types of microaggressions as bystanders in the workplace. Additionally, learners evaluated and reflected on personal behavioral changes and developments in addressing microaggressions. They also had the opportunity to apply at least one strategy during a role-play scenario with simulated participants to address an interprofessional microaggression as a bystander.

This program was developed directly in response to feedback received from internal medicine residents who wanted to address manifestations of bias in constructive and time-efficient ways. Further exploration with a needs assessment administered to the internal medicine house staff demonstrated low rates of bystander response and a high prevalence of experienced and observed microaggressions. This finding is similar to what has been observed in various settings across other health care work environments.^6,15 We intentionally displayed the results of the needs assessment, giving examples of microaggressions experienced by colleagues, as these emphasized their pervasiveness for those who did not identify with experiencing bias in the workplace.⁶ Additionally, employing simulated participants allowed our learners to hone their skills via evidenced-based experiential and active reflective processes.^26–28 The desired outcome was to empower learners to emulate and model these behaviors going forward in their careers.

In terms of implementation, our educational design was particularly unique as it was created for a virtual platform. It did not require reservation of physical space, although participants needed to have access to the virtual platform being used. Incorporating cofacilitators in these sessions allowed for varied responses to questions and comments. The virtual aspect enabled our local staff member, who assists with simulated participant-based education for trainees across the institution, to recruit from around the country (via acting-based social media groups and word of mouth), which expanded and diversified the simulated participant selection. Having a separate staff member coordinate simulated participants and manage technical issues encouraged facilitators and learners to have complete focus within the sessions. Furthermore, we acknowledged that it would be difficult to identify available local experts in the field. We therefore crafted a scripted facilitator guide accessible to those with any level of expertise. Dedicating residents’ academic half day to the curriculum encouraged engagement in the sessions with undivided attention.

Limitations, in addition to lessons learned, involve the areas of duration, coordination, and assessment. The curriculum took place over 4 hours, and some participants voiced their concerns about a long session that needed to “maintain engagement” with “high emotions.” Significant amounts of coordination and facilitator resources were needed to run each session, which may prove a challenge with a larger group of learners. Importantly, there is a current evidence gap about the effectiveness of curricular teaching on responses to bias and microaggressions; it is unclear how this links to measurable outcomes for faculty, residents, colleagues, and/or patients.^14,29 Regarding our third and fourth educational objectives, we did not specifically elicit if each learner applied a strategy to address a microaggression during the simulation or measure the extent to which learners developed an understanding of their own preferred strategies for approaching microaggressions. While our current evaluation tool measures same-day changes in self-reported confidence, incorporating a second postsurvey several days or a week later could provide a more robust long-term assessment, potentially demonstrating greater effectiveness as concepts and strategies are further processed by learners. Additionally, we opted to use pre- and postsurvey assessments because we did not pursue randomization and our sample size was small.³⁰ Since we used a convenience sampling method, a power analysis was not performed prior to implementing the curriculum. Although we were able to observe statistically significant results, we acknowledge that a 40% response rate introduces another limitation. The subpopulation of respondents who completed both the optional surveys may not be representative of the broader learning pool.

A future direction for this work would be to incorporate the curriculum earlier in the academic year for senior residents and ultimately earlier in the residency training timeline as suggested in the qualitative feedback. This would allow residents to have more training time to build upon their skills and identify their own strategies when approaching microaggressions. Earlier integration of the curriculum into residency training would also allow for much-needed serial assessment of the long-term impact. To evaluate the effectiveness of our curriculum's virtual format, a future approach could involve comparing a group of learners attending the session in person with another group participating virtually. Furthermore, while certain elements of psychological safety were established through discussing ground rules, recruiting facilitators in pairs, and orienting them on how to create a brave space, we acknowledge there are opportunities to do more for our simulated participants. We aim to provide this dedicated space in future sessions by including debriefing techniques after sessions and actively seeking feedback about simulated participants’ experiences in the cases and sessions.

Another next step for our curriculum would involve an adaptable scaffold to accommodate the experiences of learners in varying specialties. To maximize relevance for a different program, a local needs assessment might inform small changes to the curriculum program, such as differing regional examples of microaggressions or more relevant clinical context for a given specialty. While our cases capture generic (and thus readily adaptable) themes experienced across specialties, these scenarios could be further edited to reflect a specific specialty context. For example, the case involving a decompensating patient involves a diagnosis of heart failure. This description could be changed to reflect a preoperative or psychiatric condition. Finally, our curriculum can be restructured to fit within a broader longitudinal curriculum focused on diversity, equity, and inclusion. This session could be incorporated not only at a graduate trainee level but also at a student, faculty, and/or institutional level.

Our own experiences with microaggressions significantly informed the creation of the case materials. These personal encounters shaped our understanding of the complexities and nuances involved in confronting microaggressions as bystanders. We aimed to create a replicable and modifiable resource to match learners’ needs at their home institutions. We hope that our tool serves as a resource for other academic centers striving to improve their residents’ ability to recognize and respond thoughtfully to microaggressions in the workplace, thus contributing to a more welcoming and inclusive practice environment for all. Our next steps are to refine this curriculum based on feedback and research outcomes, and we recommend others to similarly incorporate personal and collective experiences into their educational resources to address this critical issue.