Setting and Problem
Numerous studies have demonstrated that clinicians' implicit racial bias contributes to health care disparities. Furthermore, this “silent curriculum” impacts the medical education provided to our trainees, and likely perpetuates cultural stereotypes. Many physicians and trainees have written essays describing distressing experiences with explicit bias. Unfortunately, despite the important role implicit and explicit bias play in our clinical learning environment, there are few faculty development resources on recognizing and addressing bias. Objective structured teaching exercises (OSTEs) have been used successfully to assess and improve faculty members' teaching abilities in a number of areas.
We utilized an OSTE as a tool to teach faculty how to identify and tackle both explicit and implicit bias. Our objectives were (1) to design a workshop using a 2-station OSTE on recognizing and managing implicit and explicit bias as part of a department-wide faculty development program; (2) to assess feasibility and acceptability of the program; and (3) to assess the effectiveness of the program using a retrospective pre-post survey.
The NYU/Bellevue Hospital Pediatric Residency Program is a multi-site urban program with 58 categorical residents, 32 fellows, and 75 core faculty. All core faculty participate annually in a department-wide faculty development session.
Intervention
We created a 2-station OSTE utilizing actors as standardized learners (SL). At 1 station, faculty helped an SL manage explicit bias against her, expressed by a family requesting a non-Muslim physician. At the second station, faculty precepted an SL on rounds who expressed implicit bias in creating a discharge plan by assuming an immigrant family was not concerned with their child's long-term cognitive development. Both scenarios were derived from true situations faced by our clinicians.
Faculty worked in pairs, each playing a member of the care team, allowing them to address the case and the SL together. This structure allowed faculty to observe and learn from one another. Each station consisted of 10 minutes performing the task, 5 minutes of self-evaluation by faculty, and 5 minutes of verbal and written feedback by the SL using a checklist. A brief didactic on bias was provided prior to the OSTE and a debriefing followed the OSTE. Participants completed an anonymous workshop assessment, using a Likert scale of 1 to 5 (exceeding expectations) to assess the OSTE and a Likert scale of 1 to 10 (effective) for the retrospective pre-post survey. The workshop was conducted twice over 6 months.
Outcomes to Date
Forty-one of 47 (87%) participating faculty completed the workshop assessment. The mean overall OSTE rating was 4.7 (range 4–5). Participants positively rated the cases and SLs as realistic, and SL feedback, didactics, and debriefing as helpful (all means > 4.5). In the retrospective pre-post survey, participants reported a significant increase in their skills in teaching trainees to recognize and address bias (from 6.0 to 7.9, P < .001). Additionally, they reported significant improvement in their own skills in recognizing and addressing bias (6.2 to 8.1, P < .001). Through informal verbal feedback, faculty noted that the opportunity to practice these skills in a simulation environment was especially valuable given the charged subject matter. This workshop can be replicated in other specialties by making minor changes in the cases. A limitation of this model is the time and funding required to train actors. (Actors were paid $25 per hour for a 2-hour training and a 1.5-hour workshop.) However, for departments willing to make a small investment, this innovative faculty development model has the potential to help address bias in the clinical learning environment.