MEDICAL SCIENCE EDUCATOR The Journal of the International Association of Medical Science Educators Med Sci Educ 2013; 23(2): 217-224
ORIGINAL RESEARCH
Challenging Medical Students to Confront their Biases: A Case Study Simulation Approach Lon J. Van Winkle1, Sophie La Salle1, Lendell Richardson2, Bryan C. Bjork1, Paulette Burdick1, Nalini Chandar1, Jacalyn M. Green1, Sean M. Lynch1, Chester Robson1 & Susan M. Viselli1 1 2
Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, IL, USA College of Health Sciences, Midwestern University, Downers Grove, IL, USA
Abstract
We used three approaches to determine whether first-year medical students would begin to confront their biases in response to a simulated encounter with an incarcerated, African-American patient. The patient presented with fatigue in a Biochemistry course workshop. Two hundred five students watched and helped a classmate conduct a simulated interview with the patient who had been imprisoned for attempted murder. We then studied whether the students confronted their biases against the patient using (a) a survey of individual students regarding these biases, (b) one of a number of questions on a formal assignment concerning the case completed in a team format, and (c) an unprompted extra-credit opportunity to reflect as a team on issues of their choice. On the survey, eighty five percent of students confronted their biases against the patient, and they began to reflect critically about these biases. Critical reflection on teams occurred more frequently outside the formally assigned exercise (Effect Size = 0.75, crucial practical importance). Thus, most first-year medical students can be led, even in basic sciences courses, to confront their biases. In this way, they may also begin to mitigate their biases against patients. Such self-regulation of biases by health care professionals on a regular basis should help to decrease health care disparities.
Introduction
Unexamined and unmitigated biases of health care professionals against patients contribute to health care disparities.1 While many disparities may be attributable to other factors, such as socioeconomic status, provider biases contribute independently.2,3 In response, patients may have or develop their own biases which cause them to seek care less often or adhere less strictly to treatment plans.4,5 Health care professionals should be able to identify their biases through critical reflection (CR).6-10 Exercises which have been used to foster such reflection in health care professional students include reading poems written by physicians, watching a performance on the challenges of aging and considering the roles of other professionals in Corresponding author: Dr. Van Winkle, Department of Biochemistry, Chicago College of Osteopathic Medicine, Midwestern University, 555 31st Street, Downers Grove, Illinois, 60515, USA; Tel: +1 (630) 515-6153; Fax: +1 (630) 515-6319; email:
[email protected]
Medical Science Educator
health care.7,9,10 Students then discuss and reflect on each of these experiences within the safety of a familiar learning team.6 The deepest CR by students and their teams seems to have occurred not within the framework of formal assignments, but rather, during optional opportunities to perform CR on topics chosen by the student teams.7 By confronting their biases in these ways on a regular basis, students could become inclined to look for their biases as part of their professional routine. If healthcare professionals identify their biases they can also develop the ability to mitigate them and, thus, to deliver better patient care with fewer health care disparities.1 However, our students were not asked explicitly to attempt to identify their biases against patients in any of these exercises. For these reasons, we wanted to determine whether first-year medical students would identify and confront their biases in response to a simulated encounter with an incarcerated, African-American patient with a chief complaint of relatively new-
© IAMSE 2013
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onset fatigue. Because we wanted students to identify their own biases, we did not indicate which biases they might already have against the patient. Instead, we left it to the students to identify their biases in response to the patient. Students were surveyed specifically about their biases separately from a workshop exercise concerning the patient. This exercise was designed to help students understand the patient’s medical/biochemical problems and begin to learn how to manage these problems and the patient himself. In keeping with our previously untested hypothesis, it was predicted that students would confront biases against the patient using CR more frequently when the opportunities to reflect were outside the formal assignments of the exercise itself.7 Such opportunities were provided not only beginning with the survey mentioned above, but also using extra-credit opportunities for teams of students to perform unprompted reflection and critical reflection on the difficulties and rewards of medicine, medical education and life.
1 Strongly Disagree 1.
2 Disagree
3 Somewhat Disagree
It was also determined whether students’ empathy scores changed in association with their encounter with an incarcerated patient using the Jefferson Scale of Empathy.11,12 In general, scores on such surveys decrease (or remain unchanged) in students during health care professional training.6,13-15 Moreover, undergraduate paramedic students display less empathy toward substance abuse patients than toward patients with an intellectual disability, acute mental illness or who attempted suicide.16 Patients with substance abuse problems likely fair better, however, when healthcare professionals take their concerns seriously and remain nonjudgmental.17 Hence, exercises that raise students’ empathy scores through confronting their biases might also contribute to better patient care with fewer disparities. The main goals of our study were to determine whether students would confront their biases and raise their empathy scores in response to an incarcerated, African-American patient.
4 Neither Agree/Disagree
5 Somewhat Agree
6 Agree
7 Strongly Agree
Having an encounter with a simulated patient in prison was very engaging 6.1 (0.9)
2.
0 (0.0) 1 (0.5) 2 (1.0) 5 (2.6) 34 (17.6) 86 (44.6) 65 (33.7) The encounter with a simulated patient in prison helped me realize how important understanding the basic sciences is to the practice of medicine. 4.6 (1.5) 3 (1.6) 23 (11.9) 15 (7.8) 47 (24.4) 51 (26.4) 36 (18.7) 18 (9.3)
3.
The encounter with a simulated patient in prison caused me to consider and study possible causes of fatigue with more interest than likely would have occurred without that exercise. 4.7 (1.5) 2 (1.0)
4.
49 (25.4)
47 (24.4)
44 (22.8)
20 (10.4)
4 (2.1)
2 (1.0)
14 (7.3)
37 (19.2)
81 (42.0)
55 (28.5)
The exercise with the simulated patient in prison helped me to see my potential biases toward patients more clearly regardless of the setting. 5.5 (1.3) 2 (1.0)
6.
11 (5.7)
The exercise with the simulated patient in prison will help me to be engaged with patients regardless of the setting or disposition of the patient. 5.8 (1.1) 0 (0.0)
5.
20 (10.4)
8 (4.2)
4 (2.1)
14 (7.3)
54 (28.0)
62 (32.3)
48 (25.0)
What biases of your own did you become aware of while watching the simulation of an incarcerated patient? (See text for summary of qualitative responses)
Table 1: Survey Regarding an Incarcerated Patient with Fatigue. Using the scale, students in the class of 2015 indicated the extent to which they agreed or disagreed with each of the statements above (193 [94%] of 205 students responded to questions 1-4 and 192 [94%] responded to question 5). Mean (and standard deviation) responses are shown to the right, and the number (% ) of students choosing a response are shown below each statement. Each mean is significantly different from neutrality; i.e., 4.00 (p
